INTRODUCTION Cancer is a disease process that begins when an abnormal cell is transformed by a genetic mutation of the cellular DNA.

As the abnormal cell is mutated, it will lose its normal control mechanisms and thus will have an unregulated growth. Moreover, the abnormal cells acquire invasive characteristics, generating changes in surrounding tissues. The cells infiltrate these tissues and gain access to lymph and blood vessels, which carry the cells to other areas of the body. This phenomenon is called metastasis, or nown in laymen!s term as cancer spread to other parts of the body. Cancer ran s third in leading causes of morbidity and mortality in the "hilippines, after communicable and cardiovascular diseases with only #$% of those cancer patients survive. Cancerous tissues &malignancies' can be divided into those of the blood and blood forming tissues such as leu emia and lymphomas and the other are (solid) tumors such as carcinomas and sarcomas. Carcinomas are cancers of epithelial cells, which are cells that cover the surface of the body, produce hormones, and ma e up glands. *+amples of carcinomas are cancer of s in and colon. ,arcomas, on the other hand, are cancers of mesodermal cells that form muscles and connective tissues such as osteosarcoma &bone cancer'.

This study pays particular attention to leu emia. .eu emia, by definition, denotes cancer of the white blood cells or cells that develop into white blood cells. Compared with (solid) tumors, leu emia remains a separate cancerous cell. /ather than forming lumps, leu emia is characteri0ed by uncontrolled proliferation and accumulation of leu ocytes. Most leu emic cells never mature into functioning leu ocytes, ma ing the body deprived of vital components of its immune system. Also, the cells accumulate in the blood and in certain organs, forcing out healthy cells and interfering with the function of that organ. The cause of most types of leu emia is not nown. *+posure to radiation or to some types of chemotherapy increases the ris of developing some types of leu emia. Certain hereditary disorders, such as Down syndrome and 1anconi!s syndrome, increase the ris as well. A virus nown as 2T.345 &human T4cell lymphotropic virus type 5', which is similar to the virus that causes A5D,, is strongly suspected of causing a rare type of lymphocytic leu emia called adult T4cell leu emia. 5nfection with *pstein4 6arr virus has been associated with an aggressive form of lymphocytic leu emia called 6ur itt!s leu emia. .astly, recent study showed that prolonged and constant use of non4 steroidal anti4inflammatory drugs &N,A5D' can ma e one at ris leu emia. There are many different types of leu emia, which usually depends to how quic ly they progress and the type of cell that become cancerous but the four most important forms are derived from only two types of cells7 lymphocytes and myelocytes. for developing

This study is focused on Acute Myelocytic .eu emia &AM.'. 5t is a life4 threatening disease in which the cells that normally develop into neutrophils, basophils, eosinophils, and monocytes become cancerous. AM. is the most common type of leu emia among adults although it affects all people of all ages. 9ith AM., the client can often have bone pain, paleness due to anemia, a tendency to bleed easily because of depleted platelets and high susceptibility to infections. The most common causes of death, which occurs on the average within three months if without treatment, are hemorrhage and uncontrolled infections. The group has chosen this case in order for them to correlate and integrate the concept of cellular aberration which they have learned in the classroom to the actual condition of the patient with Acute Myelocytic .eu emia &AM.' and associate the nursing care process in providing holistic care to a client with the said condition. This study is centered on Client DC who was admitted in Northern Mindanao Medical Center &NMMC' /everse 5solation 9ard last ,eptember 8, 8$$:. This study covered for 8 days time as the group had their e+posure at the 5solation ward under the supervision of Mrs. Nerla 6a;aga. 9ithin 8 days, the group used the nursing care process as a basis for rendering holistic care. <enerally, this study aims that at the end of the 8 wee s e+posure at NMMC 5solation ward, the group will be able to augment their nowledge in Cellular Aberration= >ncology Nursing concept? enhance their s ills in applying the necessary managements

to be done? and to develop positive attitudes and values towards the provision of holistic and quality nursing care with the Nursing Care "rocess as their ultimate basis. ,pecifically, at the end of -A hours e+posure at NMMC 5solation ward, the group will effectively and thoroughly be able to use the Nursing Care "rocess throughout the case study by7 establishing rapport to the client? obtain health history of the patient band ma e a through and obBective assessment? analy0e and discuss the client!s functional health pattern comprehensively by tracing the pathophysiology of the client!s condition? formulate nursing diagnoses in relation to the actual and potential health problems identified of the patient? plan necessary nursing interventions or formulate obBectives in solving the problems identified to achieve optimum comfort of the patient which are specific, measurable, attainable, realistic, and time4 bounded? implement the planned nursing interventions efficiently with a good nurse4 client relationship? and finally give constructive evaluation of the nursing care done to the client. 5n turn, client DC is generally e+pected to regain optimum level of functioning and adopt coping s ills in performing activities of daily living. ,pecifically, the client is e+pected to establish rapport with the student nurses? e+plain reasons of hospitali0ation? state past medical history related to present condition? identify the precipitating and predisposing factors that can possibly lead to the occurrence of the condition? discuss the management applied upon the occurrence of the disease? participate with identifying health obBectives? cooperate with the managements and health teachings that are given by the group? and verbali0e response to the management and interventions given.

PATIENTS PROFILE Demographic Data This is a case of client DC, -C years old, female, single, and is bapti0ed /oman Catholic. ,he is currently residing at their house at "uro -, "uerto, Cagayan de >ro City. ,he is in third year high school in "uerto National 2igh ,chool. ,he is the second child among # children. 2er father is a carpenter while her mother wor s as labandera. ,he was admitted last ,eptember -, 8$$:, A7-D "M with admitting diagnoses of Acute Myelocytic .eu emia &AM.' and to consider 5diopathic Thrombocytopenic "urpura &5T"'. The assessment too place last ,eptember 8, 8$$:. The source of information was the patient, the patient!s mother along with the patient!s chart with a reliability scale of # which is reliable. /eason for 2ospitali0ation The client!s mother verbali0ed (daan naman ni siya naay leu emia, adtong mi4 aging tuig man to nga gipa4admit gihapon namo siya diri ug ingon ang doctor na gi4 leu emia lagi daw a ong bataEamo lang gidala dani ay nag pula4pula man iyang panit ug daw gapang4luspad nasad bali ). The client was admitted a year ago &-$ months ago' because of AM.. The client!s mother verbali0ed that the client was admitted bac then with chief complaints of body malaise, di00iness, gum bleeding, nausea and vomiting. The complete blood count ta en

a year ago showed an increase white blood cell, neutrophil, and basophil counts and decreased red blood cells, hemoglobin, and hematocrit. The client was then diagnosed with acute myeloid leu emia secondary to anemia. They were prescribed by the

physician to confirm diagnosis by bone marrow aspiration and after confirmation, the client will go through chemotherapy for A months. 2owever, due to limited financial resources, the patient never complied with the given management. The patient only received # units of pac ed red blood cells. 5t was @ days prior to admission when the client e+perienced sudden onset of intermittent fever. 5t was relieved by rest and by consistently ta ing paracetamol, C$$ mg, after every meal= three times a day. Along with fever, the client also e+perienced general body wea ness which aggravates her fever. The client!s mother verbali0ed (mag4 sige lang na siya ug higda ay apoyan daw siya ug mag la aw4la aw). The mother also noted her daughter to be pale on the lips and on her nailbeds= palms. The client and the client!s mother believed that the wea ness might be due to poor compliance of the medication prescribed to her e+isting condition and because the client never came bac for monthly chec 4 up in the hospital due to financial constraint. The client got well, manifesting decline of symptoms li e remission of fever and can tolerate small activities after 8 days of resting and consistently ta ing paracetamol but a day prior to admission, the client noted tiny red spots in her legs and large red spots on her arms which immediately motivated her and her family to see admission. During admission, the admitting physician has the following important findings7 pale conBunctiva, nail beds, and upper and lower oral mucous membrane? petechial rash

on anterior and posterior legs, both in the left and right? ecchymoses at the forearms, both left and right? splenomegaly upon palpation at the left upper quadrant with mild tenderness? and vital signs of T4 @D.8FC, 2/4 D8 bpm, //4 8- cpm, and 6"4 -$$=A$ mm2g. "rocedures done since admission include complete blood count to determine red blood cell, white blood cell, and platelet counts of the client!s body to facilitate in determining the diagnosis of the client!s condition? blood chemistry &sodium, potassium, and creatinine' to facilitate further diagnostic measure? and blood transfusion with pac ed /6C to compensate decreased count of blood components that were found in the complete blood count. 1or further information, please refer to the diagnostic e+ams and medical management of this study. <eneral Appearance The client has small body build and is slim. According to the client she stands C feet and weighs #- ilograms. ,he has light brown comple+ion with petechiae at the right and left, upper and lower e+tremities, has coarse long hair, brown eyes, and pale lips. Gpon assessment, patient is lying in bed and appears wea as manifested by her tendency to always lie in bed and seen asleep most of the time. ,he can ambulate with slightly stooped posture, is responsive, and coherent. ,he has an 531 of "N,,, infused at left metacarpal vein. The client wears a clean paBama and clean t4shirt. No foul body odor was noted. 2ealth "erception and Management

The client!s mother claimed that it was the client!s 8 nd hospitali0ation. Client DC!s previous hospitali0ation was also related with AM.. The client was admitted a year ago &-$ months ago' because of AM.. The client!s mother verbali0ed that the client was admitted bac then with chief complaints of body malaise, di00iness, gum bleeding, nausea and vomiting. The complete blood count ta en a year ago showed an increase white blood cell, neutrophil, and basophil counts and decreased red blood cells, hemoglobin, and hematocrit. The client was then diagnosed with acute myeloid leu emia secondary to anemia. They were advised by the physician to confirm client!s diagnosis through bone marrow aspiration and after confirmation, the client will go through chemotherapy for A months. 2owever, due to limited financial resources, the patient never complied with the given management. The patient only received # units of pac ed red blood cells. Client DC!s family has no nown illnesses both in paternal and maternal side. According to the mother, common colds and cough are what her family members usually e+perience. ,he verbali0ed (ambot ba nganong gihatagan a ong bata ug ingon ani nga asa it). 5n the present admission, the client!s family tried hard to comply with the medical management that was rendered for improving her health condition e+cept for the reiterated advice of the physician to conduct bone marrow aspiration to the client. ,he was ordered to be transfused with # units of pac ed /6C and was prescribed with the following medications7 prednisolone, 8C mg, T5D? napro+en, 8C$ mg, - capsule, 65D?

and omepra0ole, 8$ mg - cap, >D. 1or further details about the drug enlisted, please refer to the drug study section of this study. The client has no restrictions with her culture and religion that hinders the managements done to her. ,he also has no nown allergy on food and drugs. The client claimed that she is non4 smo er and non4 alcoholic. 1unctional 2ealth "attern 3ital ,igns Client DC!s vital signs upon admission last ,eptember -, 8$$: were7 temperature of @D.8FC, heart rate of D8 bpm, respiratory rate of 8- cpm, and a blood pressure of -$$=A$ mm2g. The client!s vital signs upon assessment dated ,eptember 8, 8$$: were7 temperature of @AFC, a pulse rate of H# beats per minute, respiratory rate of 8# breaths per minute, and a blood pressure of --$=:$ mm2g. Nutrition= Metabolic "attern Client!s usual dietary pattern before hospitali0ation includes -4 I cups of rice and prefers vegetables and fish as patient verbali0es (ga a4on o ug ma a4 healthy para ma4 healthy na o). ,ince admission, the client is on full diet. 2er meals usually depend on the hospital!s menu. 2er brea fast include a cup of rice, piece of soft boiled egg, fried eggplant, and mil . 2er lunch include a cup of rice, fried fish, vegetables and a glass of

water. ,he usually does not eat snac s. 1inally, her dinner includes a cup of rice, fish stew and a glass of water. The client has no cultural or religious restrictions. ,he has no nown allergy on food and drugs. ,he has no dentures and has no mastication= swallowing problems. 2er usual weight is #C g. The client!s mother claimed that the client has lost # ilo weight since she had been diagnosed with AM. last year. ,he claimed of not getting cold= hot easily. ,he has good s in turgor as shown by the sudden return of s in taut over the arms which indicates good hydration of the s in. ,he stands -C@.# centimeters and #ilograms. 6asing from her weight and height, she has a body mass inde+ &6M5' of -H.#8 which denotes that the client is thin out from the normal range of -D.C4 8#.:. <enerally, she has a light brown comple+ion and is pale. 2er s in felt cool and dry to touch. There was no edema present. No presence of ascites and thyroid enlargements were observed. 2er teeth are well formed with a total number of 8D with dental caries at left and right 8 nd and -st molars. 2er tongue appears moist and light pin . 2er oral mucous membrane and gums was moist and pale with presence of halitosis. 531 of "lain Normal ,aline ,olution &"N,,' is infused at his left arm vein regulated at J3> rate at HC$ cc level. *limination 6efore hospitali0ation, the client defecates once a day in the morning with stool characteri0ed as soft and brown. 6ut upon hospitali0ation, the client verbali0ed that her elimination pattern is varied, usually happens every other day with stool characteri0ed as soft and dar brown. Client reported that she does not e+perience diarrhea and

constipation or any history of bleeding upon elimination and hemorrhoids. ,he doesn!t

-$

ma e use of la+atives and diuretics. The client!s voiding pattern is two to four times a day before hospitali0ation characteri0ed with an amber and clear urine. During admission, client voids @4# times a day with clear and dar yellow urine. The patient!s mother claimed DC has no history of idney and bladder disease and doesn!t e+perience pain or difficulty in voiding. 2er abdomen is soft and round. Normoactive bowel sounds were heard upon auscultation at all quadrants at H bowel sounds= minute. Gpon percussion, there was unusual dull sound at the left upper quadrant which denotes accumulation of fluid in the spleen and mild tenderness upon palpation at the same quadrant which denotes spleenomegaly. Costo43ertebral angle of the client was non tender. 2er last inta e was 8$$$ cc, -$#$ cc of which are ta en orally and :A$ cc of which was from the 53. 2er last output, on the other hand, was -8$$ cc= 8#F. /espiration The client doesn!t e+hibit shortness of breath and has no cough. ,he has no history of asthma, bronchitis, emphysema, T6, and pneumonia. ,he is not a smo er and was not prescribed with respiratory aids. /espiratory rate upon assessment is 8# breaths per minute, shallow and has bilateral chest e+pansion. 2er breath is regular, quiet and unlabored. The client doesn!t use her accessory muscles during respiration, no retractions and nasal flaring were observed. 3ocal and tactile fremitus are normal in all lung fields. 6reath sounds are also clear. /honchi, crac les, and whee0e were not heard upon auscultation. 3oice soundsK

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bronchophony, egophony, and whispered pectoriloquy were unclear. Cyanosis and clubbing of fingers were not observed. Circulation The client reported that she doesn!t have history of hypertension, heart trouble, rheumatic fever, an le= leg edema, phlebitis, slow healing, claudication, dysfle+ia, bleeding tendencies, palpitations, and syncope. ,he also reported that she doesn!t e+perience tingling and numbness on her e+tremities. ,he doesn!t e+perience chest pain and she told us that she doesn!t have change in urinary frequency. 6" upon lying is --$=:$ mm2g and sitting is --$=:$ mm2g. 2er radial pulse is H# beats per minute, regular and with normal pulse strength &8L'. 2er apical pulse was also HC beats per minute, regular and with normal pulse strength &8L'. 2er right and left pedal pulses is regular with normal pulse strength &8L'. Cardiac palpation, friction rub, murmurs, vascular bruit, heaves, and thrills were not heard upon auscultation. 2eart sound ,8 &dub' is greater at base than s- &lub'. *+tremities are cool to touch. 2er color is slightly pale over her light brown comple+ion. ,he has good capillary refill manifested by return of color which ta es less than 8 seconds. Mucus membrane is slightly pale and intact. The nailbeds are concave in shape with no abnormalities and is pale. ,he has pale conBunctiva and an anicteric sclera. No presence of diaphoresis was noted. "lain Normal ,aline ,olution &"N,,' is infused at his left arm vein regulated at J3> rate at HC$ cc level. /edness, swelling and edema on the 53 site are not noted. Activity= ,afety= Mobility ,tatus

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A. Activity= /est Client DC is in third year in a local high school in their area. 2er usual activities include going to school, study, tal with friends, and assist with household chores li e cleaning and washing dishes. ,ometimes, her mother won!t let her do heavy chores because of her disease. ,he spends free time strolling along the local par with friends, chit4chat with them, or te+t. 2er usual sleep pattern before admission was : hours sleep, sleeps at around : "M and wa es up A AM, and naps for at least @$ minutes in the day. During admission, she verbali0ed (sige o!g atulog, mga -$ hours, ay para ma a4pahulay o para maayo na o). 6ody build of the client is lean showing thin bilateral, developed muscle tone. 2er posture is slightly stooped. /ange of motion is active. Tremors and deformities were not noted. ,he is cooperative and her manner of speech is understandable and shows thought association. 6. 2ygiene ,he was able to perform activity of daily livings independently before admission. During admission, her activities of daily living li e hygiene, feeding, and toileting are slightly dependent on her mother. 2er mother verbali0ed (a o na siyang ga4tabangan pag liho ay luya usahay). 2owever, the client insisted that she is independent with

mobility li e turning, sitting, standing, wal ing, and dressing.

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The client upon assessment was slightly pale, with appropriate dress. 2er hair was long and was tied with good scalp condition with no presence of dandruff and vermin. There was no presence of unusual body odor. C. ,afety Client has no nown food allergies. 2er mother claimed that the client!s

immuni0ation history was complete, availed in their health center. During our rotation, she has undergone blood transfusion in ,eptember @, 8$$: with - unit pac ed /6C with segment number #C8,H8:A. There was no adverse reaction observed on the entire transfusion. The client has no fractures, arthritis, bac problems, enlarged moles and nodes. "rosthesis and ambulatory devices were not used. The client!s temperature is cool to touch. Diaphoresis was not noted. >ld scars were noted in his legs while there was presence of petechial rashes. "inpoint petchiae were noted in the legs, left and right, while large &hemorrhagic' petechaie were noted in the upper e+tremities, also both left and right. .acerations, ulcerations, ecchymoses, blister, and burns were not noted. ,he has good strength with good muscle mass tone. 2er gait is observed to be coordinated. Cognition and "erception= ,ensory /efle+es Di00iness was reported by the client. ,he verbali0ed (ga a4lipong o gamay, labi na ug mu4ba od o daretso). The client e+periences no pain but her main focus is the petechiae that she manifests. ,he eeps on chec ing and touching the petechiae. 2er

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mother eeps on as ing us on what is happening to her daughter. They also are particular to the management given to them. Client has no guarding behavior. 1acial grimacing was not observed upon assessment. ,he is alert, cooperative, coherent, and obeys to commands. ,e+uality= /eproductive Client was uncomfortable with the subBect matter. The client claimed that she is not se+ually active and doesn!t use contraceptives. The client claimed that her menarche started when she was at age -8. 2er cycle is usually 8D4 @$ days. ,he often has monthly visits and sometimes she has amenorrhea. ,he verbali0ed ( ung apoy ayo o sa

s wela, usahay dili o dug4on). ,he consumes 84@ pads a day when she will menstruate. ,he also claimed that she doesn!t now how to perform breast self e+amination. *+aminations of the private parts were not done. ,elf4 Concept= Coping Client states that her current stressor is the condition that she has now. ,he verbali0ed (di o ganahan ug in4aniEgusto o mag4 es wela). ,he copes to her stressor by constant prayer to <od and opening her feelings up to her mother and friends. 2er family is practicing /oman Catholic and is hopeful that she will be discharged soon. ,he reported to have no feelings of helplessness and powerlessness over the current situation. 2er mother whispered that because of her stay at the hospital, she has mood swings sometimes.

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3alues and 6eliefs The client is practicing /oman Catholic. 2er family has various beliefs brought about by her culture and religion. *+ample belief is that in order to achieve good health, one has to be positive and should have cheerful disposition in life. 2er family has a strong belief to the .ord that she will be healed by <od!s healing power. Developmental Task 2avighurst!s Developmental Tas Theory Adolescence &-@ to -D years' The developmental tas s that an adolescent can perform according to 2avighurst are7 -'Accepting oneMs physique and accepting a masculine or feminine role? 8' New relations with age4mates of both se+es? @' *motional independence of parents and other adults? #' Achieving assurance of economic independence? C' ,electing and preparing for an occupation? A' Developing intellectual s ills and concepts necessary for civic competence.? H' Desiring and achieving socially responsible behavior? D' "reparing for marriage and family life and? D' 6uilding conscious values in harmony with an adequate scientific world4picture. 5n the case of the client, she chooses to clean and wash dishes rather than repairing roof because for her, repair stuffs are for the masculine role. ,he is li ely attracted to the opposite se+ but is not yet committed into relationship. ,he nows how to regulate his emotions in a sense that she was able to e+press her feelings to her parents. 5n

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social behavior, she interacts with adults and children as well but interacts more on person with the same age as hers. ,he still needs assistance from the parents to develop coping behaviors li e what he has shown in coping with his current stressor. Therefore, the client partially met the 2avighurst!s developmental tas . ,he is still beginning to attain some of the tas s. ,ome tas s li e starting out independently and starting own family and relationships were not yet attained by the client since according to her, she!s still young. 1reudMs "sychose+ual Theory of "ersonality Development <*N5TA. ,TA<* &A years to "uberty' At this stage, the psychose+ual instincts of the first three stages of development &oral, anal, and phallic stage' reassert themselves at puberty. 6ut instead of being directed toward fantasy of the childMs own body, those are directed outward toward a genuine love relationship focused on heterose+ual genital se+. This is the time of turbulence when earlier se+ual urge reawa en and directs an individual outside the family circle. The client verbali0ed (di pa man o ipag uyab4 uyab ni mama ug papa ay ma a4 daot ug es wela). ,he Bust claimed that she has crushes in school and that she is courted by some guys. ,he wants to obey her parents! command and that she wants to focus in her studies, she did not involve into intimate relationships.

-H

5n this case of the client, she still undergoes in accomplishing this phase where she is building her own independence and is not yet involved with relationship with opposite se+. *ri son!s "sychosocial Theory of Development 5dentity vs. /ole Confusion *ri son stated that adolescence phase is a time where an individual tries integrating many roles &child, sibling, student, athlete, and wor er' for a self4image under role model and peer pressure. 5n the client!s case, she verbali0ed (gusto o mahimong maestra dayon mahimong good house wife puhon). Arguing, nagging and fighting are common parents and adolescent conflict, and she added that her parents are always there to guide him, in what she!s doing, where and with whom. The client!s mother verbali0ed (a o gina4 siguro ung unsa gyud iyang gusto sa iyang inabuhi mao ng ug dili o ma a4uyon niya ay sa tingin na o dili insa to, mag lalis gyud mi labon na sa iyang sinena, party8, ug uban pa...) Due to the process of identifying one!s self, our patient is still in the process of identifying image that sometimes creates conflict with parents. "iagetMs Cognitive Theory of Development &1ormal >peration stage'

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The formal operational stage is the final stage of cognitive development. This stage, which follows the Concrete >perational stage, commences at around -- years of age &puberty' and continues into adulthood. 5t is characteri0ed by acquisition of the ability to thin abstractly and draw conclusions from the information available. During this stage the young adult functions in a cognitively normal manner and therefore is able to understand such things as love, Nshades of grayN, and values. 5n this case, the client uses his rational thin ing and reasoning. At the age of -C years old, she sometimes insists to his parents that she is (old enough to ma e her own decision). Therefore, the client is initially using her rational thin ing and reasoning. 6ecause she is in the process of establishing independence of her self, rational thin ing is of great use.

DIAGNOSTIC EXAMS >n ,eptember -, 8$$:, a blood sample was ta en for Complete 6lood Count &C6C' to determine blood cell count and their relative proportions. 5t is a common blood test used to evaluate and detect hematologic disorders including anemia and leu emia. The actual C6C count ta en from the blood sample of the patient revealed a significant elevation of white blood cells= 96C &--D, $$$ u.' from the normal values of C,$$$4 -$,$$$. This signifies a dramatic increase of 96C as mostly observed in patient

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with leu emia. The red blood cell count was below normal range &8.CH + -$O= u.' from the normal range of #.84 C.# + -$OA=u.. This also signifies anemia in leu emia. 2emoglobin, the main component of /6C, which serves as the vehicle for transportation of o+ygen and carbon dio+ide is decreased into :.8 gm=d. from a normal range of &-8.$4 -A.$ gm= d.'. This indicates anemia. 2ematocrit value is the percentage of red blood cells. The result shows decreased hematocrit &@C.# %' from the normal percentage of @H4 #H %, which indicates hemodilution of the blood. Differential count of 96C showed an increase in neutrophil &DH.8%' from the normal range of #@.#4 HA.8 % and an increase in basophil &A %' from the normal range of $.$4 8.$ %. This is usually an indicative of leu emia. The platelet count is also significantly decreased &C- + -$O@=u.' from the normal range of -C$4 @$$ + -$O@=u.. The mechanism of the decrease and increase of the blood components are discussed in the pathophysiology section of this study. 6lood chemistry for sodium, potassium, and creatinine showed all normal values. "lease see appendi+ for the summary. MEDICAL MANAGEMENT 5deal Medical Management of AM. The overall obBective of treatment is to achieve complete remission, in which there is no detectable evidence of residual leu emia remaining in the bone marrow. Attempts are made to achieve remission by the aggressive administration of chemotherapy, called induction therapy, which usually requires hospitali0ation for several wee s. 5nduction therapy typically involves high doses of cytarabine &cytosar,

8$

Ara4C ' and daunorubicin & DaunoPome ' or mito+antrone & Novantrone ' or idarubicin & 5damycin ' ? sometimes etoposide &3"4 -A, 3e"esid' is added to the regimen. The choice of agents is based on the patient!s physical status and history of prior antineoplastic treatment. The aim of induction therapy is to eradicate the leu emic cells, but this is often accompanied by the eradication of the normal types of myeloid cells. Thus, the patient becomes severely neutropenic &an ANC of $ is not uncommon', anemic, and thrombocytopenic &a platelet count of less than -$,$$$=mm@ is common'. During this time, the patient is typically very ill, with bacterial, fungal, and occasionally viral infections, bleeding, and severe mucositis, which cause diarrhea and a mar ed decline in the ability to maintain adequate nutrition. ,upportive care consists of administering blood products &/6Cs and platelets' and promptly treating infections. The use of granulocytic growth factors, either <4C,1 &filgastrim QNeupogenR' or <M4C,1 &sargramostim Q.eu ineR', can shorten the period of significant neutropenia by stimulating the bone marrow to produce leu ocytes more quic ly? these agents do not appear to increase the ris of producing more leu emic cells. 9hen the patient has recovered from the induction therapy &i.e. the 96C and platelet counts have returned to normal and any infection has resolved', the patient typically receives consolidation therapy &post4remission therapy'. The goal of consolidation therapy is to eliminate any residual leu emia cells that are not clinically detectable, thereby diminishing the chance for recurrence. Multiple treatment cycles of various agents are used, usually containing some form of cytarabine &eg, cytosar, AraSC'.

8-

1requently, the patient receives one cycle of treatment that is almost the same, if not identical, to the induction treatment but uses lower dosages &therefore resulting in less to+icity'. Despite the aggressive use of chemotherapy, the li elihood of remaining in remission for a prolonged period is not great. About H$% of patients with AM. e+perience a relapse &2iddemann T 6uchner, 8$$-'. Another aggressive treatment option is bone marrow transplantation &6MT' or peripheral blood stem cell transplantation &"6,CT'. 9hen a suitable tissue match can be obtained, the patient embar s on an even more aggressive regimen of chemotherapy &sometimes in combination with radiation therapy', with the treatment goal of destroying the hematopoietic function of the patients bone marrow. The patient is then (rescued) with the infusion of the donor stem cells to reinitiate blood cell production. "atients who undergo "6,CT transplantation have a significant ris for problems with infection,

potential graft4virus4host disease & in which the donors lymphocytes QgraftR recogni0e the patients body as (foreign) host', and other complications. "6,CT has been shown to cure AM. in 8C% to C$% of patients who are at high ris for relapse or who have relapse &/adich T ,ivevers, 8$$$'. /ecent advances in understanding of the molecular biology of myeloid blast cells have resulted in a new therapeutic option. After the uncommitted stem cell differentiates into a myeloid stem cell, it e+presses a specific antigen on the cell surface, called CD@@. 5t appears that :$% of blast cells found in AM. e+press CD@@? normal hematopoietic stem cells do not e+press this antigen &/adich T ,ievers, 8$$$'. Armed with that

88

discovery, researchers developed a monoclonal antibody to target cells with the CD@@ antigen. The anti4CD@@ antibody is lin ed to a potent anti4tumor antibiotic, calicheamicin? this medication is called gemtu0umab o0ogamicin &Mylotarg'. 9hen administered, the anti4CD@@ antibody binds to cells with CD@@ antigens, and the calicheamicin causes cell death. Normal myeloid and mega aryocyte precursors have the CD@@ antigen, so the Mylotarg destroys them. "atients develop severe neutropenia and thrombocytopenia after receiving this medication. Nonetheless, Mylotarg shows promise as an effective agent against AM.. 5n elderly patients, it appears to be somewhat less to+ic than conventional induction therpy regimens. Another important option for the patient to consider is supportive care alone. 5n fact, supportive care may be the only option if the patient has significant co morbidity, such as e+tremely poor cardiac, pulmonary, renal, or hepatic function. 5n such cases, aggressive anti4leu emia therapy is not used? occasionally, hydro+yurea &eg, 2ydrae' may be used briefly to control the increase of blast cells. "atients are more commonly supported with antimicrobial therapy and transfusions as needed. This treatment approach provides the patient with some additional time at home? however, death frequently occurs within months, typically from infection or bleeding. Actual Medical Management Due to lac of financial resources, the management done was more on supportive care which only alleviates the uncomfortable signs and symptoms manifested by the client but does not generally treat leu emia.

8@

The first step the physician did during admission was to secure consent to care as this was very basic for client under admission. This is for legality purposes as every client has the right to permit or refuse to any medical management. The physician then ordered for diagnostic e+ams such as complete blood count &C6C' and serum sodium, potassium, and creatinine. The diagnostic e+ams will serve as a great determinant in aiding the physician!s diagnosis since right diagnosis matters a lot as it is the very foundation of every management. The physician also ordered the following meds7 prednisolone, 8$ mg, - cap, tid? napro+en 8C$ mg, - cap, 65D? and omepra0ole, 8$ mg,- cap, >D. The medications have their own indications and mechanism of actions but the medications serve as a preliminary therapy to the condition to slightly alleviate some uncomfortable signs and symptoms of the client. The doctor ordered to secure 531 of - liter "lain Normal ,aline ,olution &"N,,' at J3> rate as a prime line for the # units of pac ed red blood cells &"/6C' to run for four hours to compensate the decreased red blood cell count, after a cross matching to prevent further errors. 5t was also ordered by the physician to repeat C6C after transfusion of # units "/6C to evaluate the transfusion that was done to the patient. The physician put the patient under full diet to supplement the metabolic and caloric demands of the client especially that the client!s 6M5 is only -H.#8 which is below normal. The physician ordered to monitor the vital signs every four hours which is important to facilitate continuous observation of the client especially that she has abnormal blood profile &i.e. low platelet count'.5nta e and output was monitored every shift to determine the equilibrium between the inta e orally and parenterally versus the output eliminated in the body. 1inally, the physician requested to refer accordingly

8#

especially when there are unusual manifestations shown by the client to provide immediate action. >n ,eptember 8, 8$$:, the doctor requested to facilitate client!s securing of # units of pac ed /6C to run for # hours since the management is immediate as it is very vital for the patient. The doctor also ordered to continue prescribed medications to continually achieve therapeutic goals of the medications. And finally, the 531 to follow is plain N,, - liter at J3> rate as a prime line= flushing line for the blood transfusion. The physician ordered to refer accordingly for immediate action if client shows unusual manifestations. 1inally, on ,eptember @, 8$$:, the physician patient ordered to secure @ more units of "/6C after the client was able to secure - unit of pac ed /6C. The physician still has the same orders7 to monitor vital signs for continuous observation, continue meds to achieve therapeutic effect of drugs, and monitor inta e and output every shift to determine equilibrium between inta e and output.

8C

DRUG STUDY
NAM* of D/G< <eneric7 prednisolone Dose= 1requency 8$ mg, cap, tid Classification Mechanism of Action 5mmediately and completely converted to active prednisolone in the liver. 5t has anti4 inflammatory effects that may be due to the inhibition of prostaglandin synthesis. 5t also inhibits the migration of leu ocytes and macrophage to the site of inflammation as well as inhibits phagocytosis and lysosomal en0yme release. ,pecific 5ndication "rednisolone is used in the treatment of blood cell cancers &leu emia', and lymph gland cancers &lymphomas'. 6lood diseases involving destruction of platelets by the bodyMs own immune cells &idiopathic thrombocytopeni a purpura', and destruction of red blood cells by immune cells &autoimmune hemolytic anemia' can also be treated with prednisolone. Adverse *ffects 1luid T salt retention, edema, hypertension? amenorrhea, hyperhidrosis? mental disturbances? acute pancreatitis? aseptic osteonecrosis? muscle wea ness? Cushingoid state? raised intraocular pressure? visual disturbances? local atrophy? increased appetite? growth retardation. Contraindication= "recautions Contraindication7 "eptic ulcer, osteoporosis, psychoses or severe psychoneuroses, active or quiescent T6? acute infection? live vaccines "recautions7 2ypertension, C21, diabetes mellitus, infectious disease, chronic renal failure, uremia? elderly? pregnancy. Nursing 5nterventions &A"5*' Assess7 4obtain baseline weight, 6", and electrolyte levels 4mental status 4adrenal function periodically 4sign and symptoms of infection 4plasma cortisol levels "lan7 4give with food or mil to decrease <5 symptoms 5mplement7 4ta e oral forms with food to minimi0e <5 reaction 4instruct patient not to stop medication without medical advice and not to discontinue abruptly 4tell patient to ta e drug e+actly as prescribed and to ta e missed dose as soon as remembered 4teach patient about Cushingoid symptoms *valuate7 4patient repose to therapy 4adverse reactions 4understanding of drug therapy

1unctional7 Anti4 inflammatory? immunosuppre sant

Date >rdered7 ,eptember -, 8$$:

Chemical7 ,ynthetic adrenal corticosteroid

8A

DRUG STUDY
NAM* of D/G< <eneric7 Napro+en Dose= 1requency 8C$ mg, cap, 65D Classification Mechanism of Action 5nhibits cycloo+ygenas e &C>P', an en0yme necessary for prostaglandin synthesis. Decreased prostaglandin levels result o decreased inflammatory response and relief of pain. The antipyretic effect is due to decreased prostaglandin levels in the hypothalamus, resulting to an increase in peripheral blood flow, sweating, and heat loss. ,pecific 5ndication Management of mild to moderate pain Adverse *ffects di00iness, drowsiness, faigue, tremors, confusion, insomnia, an+iety, depression, tachycardia, peripheral edema, palpitations, dysrhythmia, tinnitus, hearing loss, blurred vision, nausea, anore+ia, vomiting, diarrhea, anore+ia, Baundice, cholestatic hepatitis, constipation, flatulence, cramps, dry mouth Contraindication= "recautions 2ypersensitivity, asthma, severe renal disease, ulcer disease, pregnancy Nursing 5nterventions &A"5*' Assess7 4asthma or aspirin hypersensitivity 4renal, heamtologic, and hepatic status function 4ototo+icity and visual changes 4patient and family!s nowledge of drug "lan7 4administer to patient as a whole or crushed 4<ive with foods or mil to decrease gastric symptoms 5mplement7 4tell patient to ta e full glass of water or other liquid and sit up for @$ minutes after each dose to prevent ulceration. 4Advice patient to report drug induced adverse reaction *valuate7 4relief of pain and inflammation 4patient does not develop serious drug induced adverse reacton

1unctional7 Non4 steroidal anti4 inflammatory drug &N,A5D'

6rand Name7 1lana+

Chemical7 Cycloo+ygenase 8 &C>P4 8'inhibitor

Date >rdered7 ,eptember -, 8$$:

8H

DRUG STUDY
NAM* of D/G< <eneric7 omepra0ole Dose= 1requency 8$ mg, cap, >D Classification Mechanism of Action 5nhibits both basal and stimulated gastric acid secretion by suppressing the final step in acids production, through the inhibition of the proton pump by binding to and inhibiting hydrogen4 potassium adenosine triphosphatase, the en0yme system located at the secretory surface of the gastric parietal cell. ,pecific 5ndication "revention of gastro4 duodenal ulcers induced by N,A5D in patients at ris with a need for continuous N,A5D treatment. Adverse *ffects Angina, tachycardia, bradycardia, palpitations, headache, di00iness, rash, diarrhea, abdominal pain, acid regurgitation, nausea, vomiting, constipation, flatulence, cough, upper respiratory tract infections, asthenia, and bac pain Contraindication= "recautions Contraindications7 2ypersensitivity, pregnancy, lactation, and children. Combination therapy with clarithromycin should not be used in patient with hepatic impairment. "recautions7 5n the presence of any alarm symptoms &significant unintentional weight loss, recurrent vomiting, dysphagia, hematemesis or melena' and when gastric ulcer is suspected, the possibility of malignancy should be considered since this drug mas symptoms and delay diagnosis Nursing 5nterventions &A"5*' Assess7 4 other medications patient may be ta ing for effectiveness and interaction 4 <5 system7 bowel sounds, abdomen for swelling, and loss of appetite 4 2epatic en0ymes "lan7 4 4 give before patient eats do not open, chew, or crush capsules

"roton pumb inhibitor

Date >rdered7 ,eptember -, 8$$:

5mplementation7 4 ta e as directed, ac 4 do not crush or chew capsules 4 Caution patient to avpid alcohol, salicylates, ibuprofen7 may cause <5 irritation 4 /eport severe headache, unresolved diarrhea or change in respiratory status *valuate7 4 absence of epigastric pain, swelling, fullness

8D

DIAGNOSIS OF CARE Anatomy and "hysiology 2ematopoiesis 2ematopoiesis is the development of blood cells. "renatally, hematopoiesis occurs in the yol sac , then liver, and eventually the bone marrow. 5n normal adults, it occurs in marrow and lymphatic tissues. All blood cells develop from pluripotential stem cells. "luripotential cells differentiate into stem cells that are committed to three, two or one hemopoietic differentiation pathway. None of these stem cells are morphologically distinguishable, however.

8:

A. *rythropoiesis *rythropoiesis is the development of mature red blood cells &erythrocytes'. .i e all blood cells, erythroid cells begin as pluripotential stem cells. The first cell that is recogni0able as specifically leading down the red cell pathway is the proerythroblast. As development progresses, the nucleus becomes somewhat smaller and the cytoplasm becomes more basophilic, due to the presence of ribosomes. 5n this stage the cell is called a basophilic erythroblast. The cell will continue to become smaller throughout development. As the cell begins to produce hemoglobin, the cytoplasm attracts both basic and eosin stains, and is called a polychromatophilic erythroblast. The cytoplasm eventually becomes more eosinophilic, and the cell is called an orthochromatic erythroblast. This orthochromatic erythroblast will then e+trude its nucleus and enter the circulation as a reticulocyte. /eticulocytes are so named because these cells contain reticular networ s of polyribosomes. As reticulocytes loose their polyribosomes they become mature red blood cells. 6. <ranulopoiesis <ranulopoiesis is the

development of the granulocytic white blood cells, neutrophils, eosinophils, and basophils.

,tarting at the myelocyte stage, a particular path of devilment can be determined as specific granules become visible.

@$

C. Monocyte Development .i e all blood cells, monocytes develop from pluripotential stem cells. The first committed cell along the monocyte development tract is the monoblast, a cell type virtually identical in morphology to the myeloblast of the granulocytic series. Monoblasts develop into promonocyte, a large cell with a slightly indented nucleus. "romonocytes develop into mature monocytes. D. .ymphocyte Development .ymphocytic progenitor cells originate in bone marrow. 64lymphocytes continue development in bone marrow, before migrating to other lymph organs such as lymph nodes, spleen or tonsils. T4lymphocytes continue their development in the thymus, and may also then migrate to other lymph tissues. .ymphocytes split off to their own line of stem cells quite early in development, thus the lymphocytes are considered a separate line from the entire collection of myeloid cells &erythrocytes, monocytes, neutrophils, eosinophils, basophils'. The first cell that is morphologically recogni0able as being distinct to the lymphoid line is the lymphoblast. .ymphoblasts can divide 84@ times to form prolymphocytes. "rolymphocytes will mature into 64 or T4 lymphocytes in bone marrow or thymus, respectively. "athophysiology

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Cancer is a process of uncontrolled abnormal cell growth and development. Gnder normal circumstances, cells are formed, mature, carry out their intended function, and then die. New cells are constantly regenerated in the body to replace those cells and to maintain normal cellular function. Cancer represents the disturbance of this process, which can occur in several ways. Cells may grow and reproduce in a disorgani0ed and out4of4control fashion. Cells may fail to develop properly, so they will not function normally. Cells may fail to die normally. >ne or a combination of these processes may occur when cells become cancerous. The malignant cell in AM. is the myeloblast. 5n normal hematopoiesis, the myeloblast is an immature precursor of myeloid white blood cells? a normal myeloblast will gradually mature into a mature white blood cell. 2owever, in AM., a single myeloblast accumulates genetic changes which Nfree0eN the cell in its immature state and prevent differentiation. ,uch a mutation alone does not cause leu emia? however, when such a Ndifferentiation arrestN is combined with other mutations which disrupt genes controlling proliferation, the result is the uncontrolled growth of an immature clone of cells, leading to the clinical entity of AM.. Much of the diversity and heterogeneity of AM. stems from the fact that leu emic transformation can occur at a number of different steps along the differentiation pathway. Modern classification schemes for AM. recogni0e that the characteristics and behavior of the leu emic cell &and the leu emia' may depend on the stage at which differentiation was halted.

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,pecific cytogenetic abnormalities can be found in many patients with AM.? the types of chromosomal abnormalities often have prognostic significance. The chromosomal translocations encode abnormal fusion proteins, usually transcription factors whose altered properties may cause the Ndifferentiation arrest.N 1or e+ample, in acute promyelocytic leu emia, the t&-C?-H' translocation produces a "M.4/A/U fusion protein which binds to the retinoic acid receptor element in the promoters of several myeloid4specific genes and inhibits myeloid differentiation. The clinical signs and symptoms of AM. result from the fact that, as the leu emic clone of cells grows, it tends to displace or interfere with the development of normal blood cells in the bone marrow. This leads to neutropenia, anemia, and thrombocytopenia. The symptoms of AM. are in turn often due to the low numbers of these normal blood elements. 5n rare cases, patients can develop a chloroma, or solid tumor of leu emic cells outside the bone marrow, which can cause various symptoms depending on its location. A number of ris factors for developing AM. have been identified, including7 other blood disorders, chemical e+posures, ioni0ing radiation, and genetics. N"re4leu emicN blood disorders such as myelodysplastic or myeloproliferative syndromes can evolve into AM.? the e+act ris depends on the type of MD,=M",. *+posure to anti4cancer chemotherapy, in particular al ylating agents, can increase the ris of subsequently developing AM.. The ris is highest about @VC years after chemotherapy. >ther chemotherapy agents, specifically epipodophylloto+ins and

@@

anthracyclines, have also been associated with treatment4related leu emia. These treatment4related leu emias are often associated with specific chromosomal

abnormalities in the leu emic cells. >ccupational chemical e+posure to ben0ene and other aromatic organic solvents is controversial as a cause of AM.. 6en0ene and many of its derivatives are nown to be carcinogenic in vitro. 9hile some studies have suggested a lin between occupational e+posure to ben0ene and increased ris attributable ris , if any, is slight. 5oni0ing radiation e+posure can increase the ris of AM.. ,urvivors of the atomic bombings of 2iroshima and Nagasa i had an increased rate of AM., as did radiologists e+posed to high levels of P4rays prior to the adoption of modern radiation safety practices. A hereditary ris for AM. appears to e+ist. There are numerous reports of of AM., others have suggested that the

multiple cases of AM. developing in a family at a rate higher than predicted by chance alone. The ris of developing AM. is increased threefold in first4degree relatives of patients with AM.. ,everal congenital conditions may increase the ris of leu emia? the most

common is probably Down syndrome, which is associated with a -$4 to -D4fold increase in the ris of AM.. The 1rench4American46ritish &1A6' classification system divided AM. into D subtypes, M$ through to MH, based on the type of cell from which the leu emia

@#

developed and its degree of maturity. This is done by e+amining the appearance of the malignant cells under light microscopy and=or by using cytogenetics to characteri0e any underlying chromosomal abnormalities. The subtypes have varying prognoses and responses to therapy. Although the 92> classification &see below' may be more useful, the 1A6 system is still widely used. There are eight 1A6 subtypes7 T pe Name M$ minimally differentiated acute myeloblastic leu emia M- acute myeloblastic leu emia, without maturation M8 M@ M# acute myeloblastic leu emia, with granulocytic maturation promyelocytic, or acute promyelocytic leu emia &A".' acute myelomonocytic leu emia C to!enet"#s

M#eo myelomonocytic together with bone marrow eosinophilia acute monoblastic leu emia &MCa' or acute monocytic MC leu emia &MCb' acute erythroid leu emias, including erythroleu emia &MAa' MA and very rare pure erythroid leu emia &MAb' MH acute mega aryoblastic leu emia t&-?88' MD acute basophilic leu emia

t&D?8-'&q88?q88', t&A?:' t&-C?-H' inv&-A'&p-@q88', del&-Aq' inv&-A', t&-A?-A' del &--q', t&:?--', t&--?-:'

The morphologic subtypes of AM. include many e+ceedingly rare types not included in the 1A6 system. All of them e+cept acute myeloid dendritic cell leu emia are included in the 92> classification &see below'. The following list shows these subtypes.

Acute basophilic leu emia Acute eosinophilic leu emia Mast cell leu emia Acute myeloid dendritic cell leu emia

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Acute panmyelosis with myelofibrosis Myeloid sarcoma.

Most signs and symptoms of AM. are caused by the replacement of normal blood cells with leu emic cells. A lac of normal white blood cell production ma es the patient susceptible to infections? while the leu emic cells themselves are derived from white blood cell precursors, they have no infection4fighting capacity. A drop in red blood cell count &anemia' can cause fatigue, paleness, and shortness of breath. A lac of platelets can lead to easy bruising or bleeding with minor trauma. The early signs of AM. are often vague and non4specific, and may be similar to those of influen0a or other common illnesses. ,ome generali0ed symptoms include fever, fatigue, weight loss or loss of appetite, shortness of breath, anemia, easy bruising or bleeding, petechiae &flat, pin4head si0ed spots under the s in caused by bleeding', bone and Boint pain, and persistent or frequent infections. *nlargement of the spleen may occur in AM., but it is typically mild and asymptomatic. .ymph node swelling is rare in AM., in contrast to acute lymphoblastic leu emia. The s in is involved about -$% of the time in the form of leu emia cutis. /arely, ,weetMs syndrome, a paraneoplastic inflammation of the s in, can occur with AM.. ,ome patients with AM. may e+perience swelling of the gums because of infiltration of leu emic cells into the gum tissue. /arely, the first sign of leu emia may be the development of a solid leu emic mass or tumor outside of the bone marrow, called a

@A

chloroma. >ccasionally, a person may show no symptoms, and the leu emia may be discovered incidentally during a routine blood test.

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Diagrammatic "resentation of the "athophysiology

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NURSING CARE PLAN

Assessment Nsg. 2ealth 2+.7 A case of patient DC, -C, female, single, and /oman Catholic was admitted last ,eptember -, 8$$: due to petechial rash at upper and lower e+tremity, both right and left, and paleness. ,he was diagnosed before with Acute Myeloid .eu emia &AM.'. ,he was sent to the hospital for further management of the relapse. ,ubBective Cue=s7 The client!s mother verbali0ed (ga4luya man na siya oi) >bBective Cue=s7 4 //W 8# cpm 4shallow breathing 4pale conBunctiva, nailbeds, and mucous membrane 4decreased subcutaneous fat 4mother frequently as s about her daughter!s condition .ab Datas7 4hemoglobinW :.8 g=d. 4 /6CW 8.CHOA=u. Nursing Diagnosis 5neffective tissue perfusion related to decreased hemoglobin count in the body >bBective .ong term7 At the end of -C minutes intervention, the client and her ,> will be able to verbali0e behaviors= lifestyle changes to improve circulation as client and her ,> will verbali0e understanding of her condition and wor on improving condition of the client. 5ntervention 5ndependent7 -. *+plain the how the decrease in hemoglobin contribute in an ineffective tissue perfusion 8. 5dentify necessary changes in lifestyle and assist client to incorporate disease management into AD.s. Demonstrate= encourage use of proper rela+ation and e+ercise techniques. /ationale "roviding the client with nowledge encourages them to cooperate. To encourage the client to ta e part of the management process. *valuation The goal was partially met. At the end of -C minutes intervention, the client and her ,> demonstrated behaviors= lifestyle changes to improve circulation as client will verbali0e understanding of her condition

@.

To provide the client less tension.

#.

/eview specific dietary changes= encourage to eat diet that can boost /6C

Diet can be an alternative means of increasing hemoglobin.

Dependent7 Transfuse # units of pac ed /6C.

To compensate the decreased blood count.

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NURSING CARE PLAN

Assessment Nsg. 2ealth 2+.7 A case of patient DC, -C, female, single, and /oman Catholic was admitted last ,eptember -, 8$$: due to petechial rash at upper and lower e+tremity, both right and left, and paleness. ,he was diagnosed before with Acute Myeloid .eu emia &AM.'. ,he was sent to the hospital for further management of the relapse. ,ubBective Cue=s7 The mother of the client verbali0ed (nag4niwang lagi na siya su ad adtong pag a4 hospital niaging tuig) >bBective Cue=s7 4usual weightW #C g 4 current weightW @H g 46M5 W -H.C8 4thin body build 4pale conBunctiva, nailbeds, and mucous membrane 4decreased subcutaneous fat .ab data7 4hemoglobinW :.8 g=d. 4 /6CW 8.CHOA=u. Nursing Diagnosis Nutrition, less than body requirements, related to increased metabolic demands brought about by the disease condition >bBective ,hort term7 At the end of #$ minutes intervention, the client= ,>s will be able to demonstrate behaviors= lifestyle changes to regain appropriate weight as they agree on an established nutritional plan .ong term7 At the end of @ months intervention, the client will be able to respond to interventions planned as evidenced by weight gain for at least @ g, 6M5 of -:, pin conBunctiva, nailbeds, and hemoglobin at -8.$4 -A.$ g=d. and /6C count #.84 C.# -$OA=u. 5ntervention 5ndependent7 ,hort term7 -. "rovide diet modifications &increased protein, carbohydrates, and iron rich foods 8. *ncourage patient to choose foods that are appealing "ropose a menu plan /ationale *valuation 4 The goal was partially met. - to meet metabolic needs 4 The patient and ,> was able to participate on the agreed4 upon nutritional plan. .ong4 term plans are still ongoing.

4to stimulate appetite

@.

4to promote guided nutrition

.ong Term7 Compliance on dietary plan and weigh wee ly.

4 for evaluating effectiveness of short4 term plans

Dependent7 Administer Multivitamins with 5ron Collaborative7 Consult with dietitian= nutritional team

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NURSING CARE PLAN

Assessment Nsg. 2ealth 2+.7 A case of patient DC, -C, female, single, and /oman Catholic was admitted last ,eptember -, 8$$: due to petechial rash at upper and lower e+tremity, both right and left, and paleness. ,he was diagnosed before with Acute Myeloid .eu emia &AM.'. ,he was sent to the hospital for further management of the relapse. ,ubBective Cue=s7 The client!s mother verbali0ed (ga4luya man na siya oi) >bBective Cue=s7 4 current weightW @H g 46M5 W -H.C8 4thin body build 4pale conBunctiva, nailbeds, and mucous membrane 4decreased subcutaneous fat .ab Datas7 4hemoglobinW :.8 g=d. 4 /6CW 8.CHOA=u. Nursing Diagnosis 1atigue related to general body wea ness due to decreased $8 supply to the tissues by insufficient hemoglobin count in the body secondary to anemia >bBective At the end of 8$ minutes intervention, the patient will be able to report cause of her wea ness and to be able to report sense of energy by returning to her usual activities 5ntervention 5ndependent7 -. *ncourage to verbali0e feelings of malaise and let the patient identify the cause of the wea ness "romote bed rest. "rovide quiet environment and limit stimuli. *ncourage to demonstrate active />M e+ercises 4to identify e+act causative factor of body wea ness 4to promote rest and healing. 4 to mobili0e Boints and muscles to prevent muscular atrophy 4 to enhance self concept /ationale *valuation The goal was partially met. The patient was able to verbali0e and identify causes of body malaise but failed to return to her usual activities.

8.

@.

#.

*ncourage participation in recreational activities

Dependent7 "rovide multivitamins with iron. To provide supplement in fueling body to meet demands.

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NURSING CARE PLAN

Assessment Nsg. 2ealth 2+.7 A case of patient DC, -C, female, single, and /oman Catholic was admitted last ,eptember -, 8$$: due to petechial rash at upper and lower e+tremity, both right and left, and paleness. ,he was diagnosed before with Acute Myeloid .eu emia &AM.'. ,he was sent to the hospital for further management of the relapse. ,ubBective Cue=s7 The mother verbali0ed (gi4 advisan mi nga magpa4 chemo lagi a ong ana pero wala man mi warta) >bBective Cue=s7 4father!s occupation7 carpenter 4mother!s occupation7 labandera 4refusal for bone marrow aspiration 4refusal to undergo chemotherapy Nursing Diagnosis 5neffective therapeutic regimen management related to economic difficulties >bBective At the end of -C minutes intervention, the client and her ,> will be able to participate in problem solving of factors interfering with the integration of therapeutic regimen as patient and her ,> will be able to allow bone marrow aspiration and chemotherapy 5ntervention 5ndependent7 -. *mphasi0e importance of client nowledge and understanding of the need for treatment as well as consequences of actions= choices. 8. Assist client and her ,> to participate in the planning process. Mobili0e= identify support systems to help them financially &"C,> or A6,4 C6N ,agip Japamilya' /ationale Jnowledge about the treatment regimen will facilitate the client and her ,> to cooperate with the management. To enable the client and her ,> to ta e part of the management. To give them alternatives to answer the medical needs of the client. *valuation The goal was not met. After -C minutes of intervention, the client and her ,> participated 5 problem solving of factors that interfere with integration of therapy but still refused to allow bone marrow aspiration and chemotherapy.

@.

Dependent7 1acilitate compliance on therapeutic regimen.

To achieve the desired goal of the therapy.

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NURSING CARE PLAN

Assessment Nsg. 2ealth 2+.7 A case of patient DC, -C, female, single, and /oman Catholic was admitted last ,eptember -, 8$$: due to petechial rash at upper and lower e+tremity, both right and left, and paleness. ,he was diagnosed before with Acute Myeloid .eu emia &AM.'. ,he was sent to the hospital for further management of the relapse. ,ubBective Cue=s7 The mother verbali0ed (gi4 advisan mi nga magpa4 chemo lagi a ong ana pero wala man mi warta) >bBective Cue=s7 4father!s occupation7 carpenter 4mother!s occupation7 labandera 4refusal for bone marrow aspiration 4refusal to undergo chemotherapy Nursing Diagnosis Noncompliance to therapeutic regimen management related to economic difficulties >bBective At the end of -C minutes intervention, the client and her ,> will be able to participate in problem solving of factors interfering with the integration of therapeutic regimen as patient and her ,> will be able to allow bone marrow aspiration and chemotherapy 5ntervention 5ndependent7 -. *mphasi0e importance of client nowledge and understanding of the need for treatment as well as consequences of actions= choices. 8. Assist client and her ,> to participate in the planning process. Mobili0e= identify support systems to help them financially &"C,> or A6,4 C6N ,agip Japamilya' /ationale Jnowledge about the treatment regimen will facilitate the client and her ,> to cooperate with the management. To enable the client and her ,> to ta e part of the management. To give them alternatives to answer the medical needs of the client. *valuation The goal was not met. After -C minutes of intervention, the client and her ,> participated 5 problem solving of factors that interfere with integration of therapy but still refused to allow bone marrow aspiration and chemotherapy.

@.

To achieve the desired goal of the therapy. Dependent7 1acilitate compliance on therapeutic regimen.

##

NURSING CARE PLAN

Assessment Nsg. 2ealth 2+.7 A case of patient DC, -C, female, single, and /oman Catholic was admitted last ,eptember -, 8$$: due to petechial rash at upper and lower e+tremity, both right and left, and paleness. ,he was diagnosed before with Acute Myeloid .eu emia &AM.'. ,he was sent to the hospital for further management of the relapse. &A ris diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention' Nursing Diagnosis /is for inBury related to abnormal blood profile secondary to decreased platelet count= thrombocytopenia >bBective At the end of -C minutes nursing intervention, the client will be able to demonstrate behaviors and lifestyle changes to reduce ris factors and protect self from inBury. 5ntervention 5ndependent7 -. "rovide information regarding disease= condition that may result in increased ris of inBury. 8. 5dentify interventions= safety devices to promote safe physical environment and individual safety &e.g. clear environment from ha0ardous materials, etc.' Discuss importance of self4 monitoring of conditions that can contribute to occurrence of inBury &fatigue, anger, irritability' /ationale 5nformation could encourage the client to participate in achieving the goals. To provide health teachings and preventive measures to avoid complications. *valuation The goal was met. At the end of -C minutes nursing intervention, the client was able to demonstrate behaviors and lifestyle changes to reduce ris factors and protect self from inBury.

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The action serves as a preventive measure in the consequences of the emotions and situations.

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NURSING CARE PLAN

Assessment Nsg. 2ealth 2+.7 A case of patient DC, -C, female, single, and /oman Catholic was admitted last ,eptember -, 8$$: due to petechial rash at upper and lower e+tremity, both right and left, and paleness. ,he was diagnosed before with Acute Myeloid .eu emia &AM.'. ,he was sent to the hospital for further management of the relapse. &A ris diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention' Nursing Diagnosis /is for infection related to altered immunologic responses related to disease process. >bBective At the end of -C minutes nursing intervention, the patient will be able to verbali0e understanding of individual causative or ris factors of infection. 5ntervention 5ndependent7 -. Note ris factors for occurrence of infection &e.g. compromised host, s in integrity, environmental e+posure' 8. ,tress proper handwashing techniques @. Maintain sterile technique for invasive procedures &53' #. Monitor visitors=caregivers C. 5nstruct patient to brush teeth with soft toothbrush # times a day and as necessary. A. Discuss the role of smo ing in respiratory infection. H. /eview individual nutritional needs, appropriate e+ercise program, and need for rest D. *mphasi0e necessity of ta ing antibiotics as directed &e.g. dosage T length of therapy' Dependent7 Admit to reverse isolation ward. /ationale 4to assess causative= contributing factors 4a first4line defense against nosocomial infections=cross4 contamination. 4to prevent contamination=infection 4to prevent e+posure of patient 4for oral hygiene and prevent bacterial contamination 4to promote health teaching 4to promote wellness *valuation The goal was met. At the end of -C minutes nursing intervention, the client and her ,> was able to verbali0e understanding of individual causative or ris factors.

4"remature discontinuation of treatment when patient begins to feel well may result in return of infection.

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PROGNOSIS The prognosis of a patient usually depends on the following factors7 -' "atient!s age and race 4 Xounger patients and Caucasians have a good prognosis, while patients older than A$ years and patients of African4 American descent have a poor prognosis? 8' ,ubtype of AM. 4 M@ has good prognosis while the MH type has poor prognosis? @' "atient!s response to therapy? AM. that follows myelodysplastic syndrome or

myeloproliferative diseases has a poor prognosis? dehydrogenase #' *levated levels has a lactate poor

prognosis? and C' Cytogenetics plays an important role in predicting the progress of an AM. patient as represented in the table. 5n the case of the client, we can poorly define her prognosis since she hasn!t gone through e+tensive diagnostic e+ams. 2owever, in our Budgment basing from the supportive management given to her, she will relatively have poor prognosis. ,he will have an increase chance of relapsing since the management only aims to sustain the consequences of her disease but not totally alleviate the malignancies. Thus, with the observation we have done, we can say that the patient totally has poor prognosis.

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DISC$ARGE PLAN *ducation in health care is essential. 1or the client, we focused teachings on compliance to management prescribed &bone marrow aspiration and chemotherapy', her medications, and diet. 9e stressed the importance of ta ing her medications as we directed and advised her of the side effects. 9e stressed the importance of ta ing her medications on a regular basis as ordered by the doctor. 9e also discussed with our patient the other important option for the patient to consider chemotherapy from is supportive care. ,upportive care maybe the only option the patient has because of economic difficulties. 5n such cases, aggressive anti4leu emia therapy is not used? this treatment approach provides the patient with some additional time at home? however, death frequently occur within months, typically for infection or bleeding and so, to prevent this, we encouraged our patient to be more careful on her activities, to the food that she is eating and to be more disciplined in whatever she does most especially on ways to prevent infection and bleeding. 1inally, we educated our patient to frequently visit her doctor=s and follow scheduled chec 4ups. 9e have also given the patient general information about her disease, for her to recogni0e the recurring signs and symptoms. 5t will also be important for our patient to have both physical and emotional support from her family and friends.

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E%ALUATION The obBectives of this case study both for the client and students are fully met. The group augmented their nowledge in Cellular Aberration= >ncology Nursing

concept? enhanced their s ills in applying the necessary managements to be done? and developed positive attitudes and values towards the provision of holistic and quality nursing care with the Nursing Care "rocess as their ultimate basis. ,pecifically, the students established rapport to the client? obtained health history of the patient and made a through and obBective assessment? analy0ed and discussed the client!s functional health pattern comprehensively? formulated nursing diagnoses in relation to the actual and potential health problems identified? planned necessary nursing interventions and formulated obBectives in solving the problems identified which are specific, measurable, attainable, realistic, and time4 bounded? implemented the planned nursing interventions efficiently with a good nurse4 client relationship? and finally gave constructive evaluation of the nursing care done to the client. 5n turn, client DC is regained optimum level of functioning and adopted coping s ills in performing activities of daily living. ,pecifically, the client is established rapport with the student nurses? e+plained reasons of hospitali0ation? stated past medical history related to present condition? identified the precipitating and predisposing factors that lead to the occurrence of the condition? discussed the management applied upon the occurrence of the disease? participated with identifying health obBectives? cooperated with the managements and health teachings that are given by the group? and verbali0ed response to the management and interventions given.

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&I&LIOGRAP$Y 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Ac ley, 6. Y. T .adwig <. 6. &-::C'. Nursing Diagnosis 2andboo . A <uide to "lanning Care &8nd ed.'. "hiladelphia7 Mosby4Xear 6oo , 5nc. 6lac , Y. M. T 2aw s, Y. 2. &8$$C'. Medical4,urgical Nursing. Clinical Management for "ositive >utcomes &Hth ed.'. ,ingapore7 *lsevier 5nc. Carpenito4Moyet, .. Y. &8$$#'. 2andboo of Nursing Diagnoses &-$th ed.'. "hiladelphia7 .ippincott 9illiams T 9il ins. Doenges, M. *. et. al. &8$$8'. Nursing Care "lans. <uidelines for individuali0ing Care &Ath ed.'. "hiladelphia7 1. A. Davis Company. Doenges, M. *., et. al. &8$$#'. Nurses "oc et <uide. Diagnoses, 5nterventions, and /ationales. &:th ed.'. "hiladelphia7 1. A. Davis Company. 1ischbach, 1. &-::8'. A Manual of .aboratory and diagnostic Tests &#th ed.'. "hilalephia7 Y. 6. .ippincott Company. 5gnatavicius, D. D. T 6ayne, M. 3. &-::-'. Medical4,urgical Nursing. A Nursing "rocess Approach. "hiladelphia7 9. 6. ,aunders Company. Jarch, A. M. &8$$A'. 1ocus on Nursing "harmacology &@rd ed.'. "hiladelphia7 .ippincott 9illiams T 9il ins. Jo0ier, 6., et. al. &8$$#'. 1undamentals of Nursing &Cth ed.'. ,ingapore7 "earson *ducation ,outh Asia "T* .TD. "aradiso, C. &-::C'. .ippincott!s /eview ,eries. "athophysiology. "hiladelphia7 Y. 6. .ippincott Company. "hillips, N. 1. &8$$#'. 6erry T John!s >perating /oom Technique &-$th ed.'. ,ingapore7 Mosby, 5nc. ,melt0er, ,. C. T 6are, 6. <. 6runner and ,uddarth!s Te+tboo of Medical and ,urgical Nursing &-$th ed.'. "hiladelphia7 .ippincott 9illiams T 9il ins. ,uddarth, D. ,. &-::-'. The .ippincot Manual of Nursing "ractice &Cth ed.'. "hiladelphia7 Y. 6. .ippincott Company. Zuiambao4Gdan, Y. &8$$8'. Medical4,urgical Nursing7 Concepts and Clinical Application &-st ed.'. "hilippines7 <uiani "rints 2ouse.

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