University of Makati

College of Nursing

Medical Surgical Nursing I

A 19 year old male with ACUTE MYELOID LEUKEMIA

MEDICAL SURGICAL NURSING I

Submitted By:

BSN III-BN

Baroman, Julie
Blanco, Josephus
Cama, Precious Aura Aphrodite
De leon, Michael Dominic
Dulay, Kayte Christer
Marcelino, Regine
Patagoc, Janyss April
Romano, Jake Khail
Sanchez, Janine
 TALBLE OF CONTENTS

I. Introduction...................................................................................

II. Objectives.......................................................................................

III. Chief Compliant............................................................................

IV. History of Present Illness..............................................................

V. Review of System..........................................................................

VI. Past Medical History....................................................................

VII. Family History..............................................................................

VIII. Personal and Social History........................................................

IX. Physical Examination..................................................................

X. Medical and Nursing Diagnosis..................................................

XI. Differential Diagnosis..................................................................

XII. Anatomy and Physiology............................................................

XIII. Pathophysiology……………………………………………….

XIV. Laboratory/ Diagnostic tests......................................................

XV. Nursing Care Plan......................................................................

XVI. Drug Study..................................................................................

XVII. Discharge Plan...........................................................................

 INTRODUCTION

The group selected this case of Acute Myeloid Leukemia (AML) to enhance the

students’ knowledge concerning its clinical manifestations, possible causes, cure and prevention,

among others. This knowledge will eventually become an indispensable tool that can be shared

to others and will never go out of style. It is a privilege to embrace this challenge in the form of

service to humanity and the fulfillment of nursing profession. The group’s core competence is

the bare essential towards its success.

As a nursing profession, it is imperative to learn new techniques in modern science in

order to develop skills that would benefit the medical world. This learning potential must be

relayed to posterity and develop new techniques, state -of –the- art technology that caters the

modern man. In the final analysis, the achievement of one’s endeavor may usher us to find the

light we are seeking for.

Leukemias are cancers of the blood-forming tissues. White blood cells may be produced

in excessive amounts and are unable to work properly which weakens the immune system.

The blood is made up of fluid called plasma and three types of cells and each type has

special functions. White blood cells (also called WBCs or leukocytes) help the body fight
infections and other diseases. Red blood cells (also called RBCs or erythrocytes) carry oxygen

from the lungs to the body’s tissues and take carbon dioxide from the tissues back to the lungs.

The red blood cells give blood its color. Platelets (also called thrombocytes) help form blood

clots that control bleeding.

Blood cells are formed in the bone marrow, the soft, spongy center of bones. New

(immature) blood cells are called blasts. Some blasts stay in the marrow to mature. Some travel

to other parts of the body to mature.

Normally, blood cells are produced in an orderly, controlled way, as the body needs

them. This process helps keep us healthy. When leukemia develops, the body produces large

numbers of abnormal blood cells. In most types of leukemia, the abnormal cells are white blood

cells. The leukemia cells usually look different from normal blood cells, and they do not function

properly.

In both men and women, leukemia incidence is highest among whites and lowest among

Chinese, Japanese, and Koreans. The incidence in men is about 50% higher than in women for

all racial/ethnic groups except Vietnamese, among whom the male rates are only slightly higher.

Ethnic differences in the incidence rates are small in the youngest adult age group (30-54 years),

but become more evident in each of the older age groups. It is found that

childhood leukemia rates are highest among Filipinos, followed by white Hispanics, non-

Hispanic whites and blacks.

The types of leukemia can be grouped based on how quickly the disease develops and

gets worse. Leukemia is either chronic (which usually gets worse slowly) or acute (which usually

gets worse quickly):

• Acute leukemia: The leukemia cells can't do any of the work of normal white blood

cells. The number of leukemia cells increases rapidly. Acute leukemia usually worsens

quickly.

• Chronic leukemia: Early in the disease, the leukemia cells can still do some of the work

of normal white blood cells. People may not have any symptoms at first. Doctors often

find chronic leukemia during a routine checkup - before there are any symptoms.

Slowly, chronic leukemia gets worse. As the number of leukemia cells in the blood

increases, people get symptoms, such as swollen lymph nodes or infections. When

symptoms do appear, they are usually mild at first and get worse gradually.

The types of leukemia also can be grouped based on the type of white blood cell that is

affected. Leukemia can start in lymphoid cells or myeloid cells. Leukemia that affects

lymphoid cells is called lymphoid, lymphocytic, or lymphoblastic leukemia. Leukemia

that affects myeloid cells is called myeloid, myelogenous, or myeloblastic leukemia.

There are four common types of leukemia:

• Chronic lymphocytic leukemia (CLL): CLL affects lymphoid cells and usually grows

slowly. It accounts for more than 15,000 new cases of leukemia each year. Most often,

people diagnosed with the disease are over age 55. It almost never affects children.

• Chronic myeloid leukemia (CML): CML affects myeloid cells and usually grows

slowly at first. It accounts for nearly 5,000 new cases of leukemia each year. It mainly

affects adults.

• Acute lymphocytic (lymphoblastic) leukemia (ALL): ALL affects lymphoid cells and

grows quickly. It accounts for more than 5,000 new cases of leukemia each year. ALL is

the most common type of leukemia in young children. It also affects adults.
 • Acute myeloid leukemia (AML): AML affects myeloid cells and grows quickly. It

accounts for more than 13,000 new cases of leukemia each year. It occurs in both adults

and children.

CELL TYPE ACUTE CHRONIC

Lymphocytic leukemia Acute lymphoblastic leukemia Chronic lymphocytic leukemia
(or "lymphoblastic") (ALL) (CLL)
Myelogenous leukemia Acute myelogenous leukemia
Chronic myelogenous
(also "myeloid" or (AML)
leukemia (CML)
"nonlymphocytic")

ACUTE MYELOID LEUKEMIA

Is also called Acute myelogenous leukemia (AML). It is a malignant disease of the bone

marrow in which hematopoietic precursors are arrested in an early stage of development. Most

AML subtypes are distinguished from other related blood disorders by the presence of more than

20% blasts in the bone marrow. Estimates of new cases of acute myelogenous leukemia

(AML) in the United States in 2007 were 13,410 (7060 men; 6350 women).

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.It is more

common in men than in women.

PATIENT’S BIOGRAPHIC DATA

 Client Edgar Magallanes is a 19 year old Filipino born on the 31st of August 1991, single

and a roman catholic currently residing at Olivares Compound, Parañaque City. He has a 1

sibling, his mother is a plain housewife and his father is a farmer who pays the hospital bills.

CHIEF COMPLAINT

The client is admitted to the hospital complaining of on and off fever with 38.7◦C for 3 weeks.

HISTORY OF PRESENT ILLNESS

According to his parents 1 month prior to admission patient had small, red and painful oral sores

at the lower oral mucosa. 3 weeks prior to admission his oral thrush had swelled and increased in

size. He experience high grade on and off fever due to self medication of paracetamol. 2 weeks

prior to admission he was observed of having weight loss due to loss of appetite until the

admission to the hospital.

REVIEW OF SYSTEM

General Appearance

Weight loss

Fatigue

Sweat

• Head and neck

a. Headache

• Ears

No significant findings
 • Nose

No significant findings

Integumentary

Pale Skin

Bleeding lip

Sores

Respiratory

No significant findings

Cardiac

No significant findings

Nervous system

Headache

Dizziness

Fever

G.i

Sores

Musculoskeletal

Joint pains

Weakness

PAST MEDICAL HISTORY

It was the patients’ first admission , August 15, 2010 and according to the mother, he has

no allergy to any food or medication. The client completed the Expanded Program for

Immunization.
 FAMILY HISTORY

GRAND-
GRANDFATHE FATHER
MOTHER
R GRAND-
MOTHER

FATHER
MOTHE
R

CLIENT @

- Leukemia

- Healthy
 @ - Acute Lymphocytic Leukemia

PERSONAL AND SOCIAL HISTORY

The patient belongs to a lower class family wherein his father is a farmer and his mother

is a housewife. Their house is made of wood with one bedroom, one water-sealed toilet and three

windows with enough ventilation. Garbage disposal is collected by garbage truck daily,

segregated. They are four in their family. The patient is a public high school graduate somewhere

in Olivares. Diet /food are mostly fish and vegetables. The patient doesn’t smoke. The patient

occasionally drink about 3-5 bottles. The patient doesn’t conduct regular check-up.

PHYSICAL EXAMINATION

General Appearance:

Mr. Magallanes is a young adult male who looks pale and acutely ill. He is conscious, awake, coherent

and interactive, with good eye contact; he is well oriented to time, person and place. He cannot speak

more than two to three words at a time because of shortness of breath; he is sweating and has an anxious

face with chills. He is fairly developed with no physical deformities. He has a small frame body built with
a BMI of 15 ²; he is with diffuse muscle wasting. Client has an unpleasant odor and has halitosis. He

prefers lying down in bed. Height is 5’6”, weight 54 kilograms, BP 110/80, PR 84bpm and irregular, RR

22cpm labored, an elevated temperature with a reading of 39.3ᴼC.

Skin:

He has an unexplained bruising (ecchymosis) and petechiae; without obvious lesions, scarring, scaling

and rashes. Skin is warm and smooth. He has no form of sores and has no signs of bleeding.

Nails:

Nails are pallor, Leukonychia is seen; capillary refill is longer than 3 seconds, there is a presence of nail

clubbing. Nails are cut short and clean.

Head and Face:

Hair is fine with average texture, oily and thin and is equally distributed. Scalp is good with no presence

of scaling and scars, no tenderness is noted. Skull is normocephalic/atraumatic. Face is symmetrical with

no deformities; with anxious face and grimace. Face is fine and pale with localized acne on the forehead.

Eyes:

Conjunctivas are pale, pupils are equally rounded and are reactive to light and accommodations, the sclera

is white, bulbar is clear and palpebral is pink. Disc margins are sharp and no hemorrhages or exudates

were seen and no arteriolar narrowing was noted. With a 20/20 vision, eyes are properly aligned and

positioned. He has no visual difficulties and is not using reading glasses or contact lenses. Eyebrows are

equally distributed, and no presence of sty, chalazion or ptosis in the eyelids.

Ears:
Ears are both symmetrically in position with no signs of scarring and have no lesions. Pinna recoils when

folded, no pain was noted when moving the auricle up and down, no swelling and erythemas were seen.

Acuity is good to whispered voice. Tympanic membranes are good and with good cone of light.

Nose:

Nasal mucosa is pink, nasal septum is aligned, at midline and no deformities were seen. The frontal

maxillary sinuses were palpated and no signs of tenderness were noted.

Mouth:

Lips and Oral mucosa are reddish in color with the presence of oral thrush in the right lower mucosa, with

halitosis.

Neck:

Trachea is aligned and in midline. Neck is supple and thyroid isthmus is palpable, lobes are not felt.

Lymph nodes were palpable and no presence of cervical, axillary, epitrochlear and inguinal adenophaty

were noted.

Chest and Lungs:

Thorax is symmetric with fast expansions; with an RR of 22cpm. He is with moderate khyposis and is

experiencing difficulty in breathing. Anteroposterior to lateral ratio 1:2 lungs are resonant, breath sounds

vesicular; no rales, wheezes, or rhonchi. Diaphragms descend 4cm bilaterally. Breasts are symmetric and

without masses. Nipples are without discharge.

Abdomen:

Abdomen is flat. Bowel sounds are heard with a rate of 13bpm. It is boardlike and firm, with increased

tenderness, guarding, cramping, non-radiating hypogastric pain with a pain scale of 8/10. Spleen and liver
 were palpated and kidneys not felt, liver span is 7 cm and in the right MCL; edge is palpable 1cm below

the right costal margin. No CVA tenderness.

Upper and Lower Extremities:

Extremities are warm and without edema; with presence of petichiae and ecchymosis. No varicosities or

stasis changes. Calves are supple and no tenderness. No femoral or abdominal bruits. Brachial, radial,

femoral, popliteal, dorsalis pedis and posterior tibial pulses are 2+ and symmetric.

Radial | Brachial | Femoral | Popliteal | Dorsalis Pedis | Posterior Tibial |

RT 2+ 2+ 2+ 2+ 2+ 2+

LT 2+ 2+ 2+ 2+ 2+ 2+

DIAGNOSIS: Acute Lymphocytic Leukemia

DIFFERENTIAL DIAGNOSIS

ACUTE CHRONIC ACUTE CHRONIC

LYMPHOCYTIC LYMPHOCYTIC MYELOGENOUS MYELOGENOUS
LEUKEMIA LEUKEMIA LEUKEMIA LEUKEMIA

Most common type of Most often affects occurs more commonly occurs mainly in adults.
leukemia in children adults over the age of in adults than in A very small number of
and also affects adults, 55. It sometimes children, and more children also develop
especially those age 65 occurs in younger commonly in men than this disease.
and older adults, but it almost women.
never affects children.
The survival rates vary The five-year survival The five-year survival The five-year survival
by age: 85% in children rate is 75%. rate is 40%. rate is 90%
and 50% in adults.
Standard treatments It is incurable. AML is treated with Treatment is with
involve chemotherapy chemotherapy imatinib (Gleevec) or
and radiation. other drugs.
Affects lymphoid cell Affects lymphoid cell Affects myeloid cell Affects myeloid cell

ANATOMY AND PHYSIOLOGY

Blood

Blood is one of the connective tissues. As a connective tissue, it consists of cells and cell

fragments (formed elements) suspended

in an intercellular matrix (plasma).

Blood is the only liquid tissue in the

body that measures about 5 liters in the

adult human and accounts for 8 percent

of the body weight.

The body consists of metabolically

active cells that need a continuous

supply of nutrients and oxygen. Metabolic waste products need to be removed from the cells to

maintain a stable cellular environment. Blood is the primary transport medium that is responsible

for meeting these cellular demands.

Blood cells are formed in the bone marrow, the soft, spongy center of bones. New (immature)

blood cells are called blasts. Some blasts stay in the marrow to mature. Some travel to other parts

of the body to mature.

The activities of the blood may be categorized as transportation, regulation, and protection.
These functional categories overlap and interact as the blood carries out its role in providing

suitable conditions for celluar functions.

The transport functions include:

 carrying oxygen and nutrients to the cells.

 transporting carbon dioxide and nitrogenous wastes from the tissues to the lungs and

kidneys where these wastes can be removed from the body.

 Carrying hormones from the endocrine glands to the target tissues.

The regulation functions include:

 Helping regulate body temperature by removing heat from active areas, such as skeletal

muscles, and transporting it to other regions or to the skin where it can be dissipated.

 Playing a significant role in fluid and electrolyte balance because the salts and plasma

proteins contribute to the osmotic pressure.

 Functioning in pH regulation through the action of buffers in the blood.

The protection functions include:

 Preventing fluid loss through hemorrhage when blood vessels are damaged due to its

clotting mechanisms.

 Helping (phagocytic white-blood cells) to protect the body against microorganisms that

cause disease by engulfing and destroying the agent.

 Protecting (antibodies in the plasma) protect against disease by their reactions with

offending agents.

Composition of blood

When a sample of blood is spun in a centrifuge, the

cells and cell fragments are separated from the liquid

intercellular matrix. Because the formed elements are

heavier than the liquid matrix, they are packed in the bottom of the tube by the centrifugal force.

The light yellow colored liquid on the top is the plasma, which accounts for about 55 percent of

the blood volume and red blood cells is called the hematocrit,or packed cell volume (PCV).

The white blood cells and platelets form a thin white layer, called the “buffy coat,” between

plasma and red blood cells.

Plasma

The watery fluid portion of blood (90 percent water) in which the corpuscular elements are

suspended. It transports nutrients as well as wastes throughout the body. Various compounds,

including proteins, electrolytes, carbohydrates, minerals, and fats, are dissolved in it.

Formed Elements

The formed elements are cells and cell fragments suspended in the plasma. The three classes of

formed elements are the erythrocytes (red blood cells), leukocytes (white blood cells), and the

thrombocytes (platelets).

Erythrocytes (red blood cells)

Erythrocytes, or red blood cells, are the most numerous of the formed elements. Erythrocytes are

tiny biconcave disks, thin in the middle and thicker around the periphery. The shape provides a

combination of flexibility for moving through tiny capillaries with a maximum surface area for

the diffusion of gases. The primary function of erythrocytes is to transport oxygen and, to a

lesser extent, carbon dioxide.

Leukocytes (white blood cells)

Leukocytes or white blood cells are generally larger than erythrocytes, but they are fewer in

number. Even though they are considered to be blood cells, leukocytes do most of their work in

the tissues. They use the blood as a transport medium. Some arephagocytic, others produce
antibodies, some secrete histamine and, heparin, and others neutralize histamine. Leukocytes are

able to move through the capillary walls into the tissue spaces, a process called diapedesis. In the

tissue spaces they provide a defense against organisms that cause disease and either promote or

inhibit inflammatory responses.

There are two main groups of leukocytes in the blood. The cells that develop granules in the

cytoplasm are called granulocytes and those that do not have granules are called agranulocytes.

Neutrophils, eosinophils, and basophils are granulocytes. Monocytes and lymphocytes are

agranulocytes.

Neutrophils, the most numerous leukocytes, are phagocytic and have light-colored granules.

Eosinophils have granules and help counteract the effects of histamine. Basophils secrete

histomine and heparin and have blue granules. In the tissues, they are called mastcells.

Lymphocytes are agranulocytes that have a special role in immune processes. Some attack

bacteria directly; others produce antibodies.

Thrombocytes (platelets)

Thrombocytes, or platelets, are not complete cells, but are small fragments of very large cells

called megakaryocytes. Megakaryocytes develop from hemocytoblasts in the redbone marrow.

Thrombocytes become sticky and clump together to form platelet plugs that close breaks and

tears in blood vessels. They also initiate the formation of blood clots.
 Blood

Cell

Lineage:

The production of formed elements, or blood cells, is called hemopoiesis. Before birth,

hemopoiesis occurs primarily in the liver and spleen, but some cells develop in the thymus,

lymph nodes, and red bone marrow. After birth, most production is limited to redbone marrow in

specific regions, but somewhite blood cells are produced in lymphoid tissue.

All types of formed elements develop from a single cell type – stem cell (pleuripotential cells or

hemocytoblasts). Seven different cell lines, each controlled by a specific growth factor, develop

from the hemocytoblast. When a stem cell divides, one of the “daughters” remains a stem

cell and the other becomes a precursor cell, either a lymphoid cell or a myeloid cell. These cells

continue to mature into various blood cells.

Leukemia can develop at any point in cell differentiation. The illustration below shows the

development of the formed elements of the blood.

Blood-related cancers, or leukemias, have been shown to arise from a rare subset of cells that

escape normal regulation and drive the formation and growth of the tumor. The finding that these
so-called cancer stem cells, or leukemic stem cells (LSC), can be purified away from the other

cells in the tumor allows their precise analysis to identify candidate molecules and regulatory

pathways that play a role in progression, maintenance, and spreading of leukemias. The analyses

of the other, numerically dominant, cells in the tumor, while also interesting, do not directly

interrogate these key properties of malignancies. Mouse models of human myeloproliferative

disorder and acute myelogenous leukemia have highlighted the remarkable conservation of

disease mechanisms between both species. They can now be used to identify the LSC for each

type of human leukemia and understand how they escape normal regulation and become

malignant. Given the clinical importance of LSC identification, the insights gained through these

approaches will quickly translate into clinical applications and lead to improved treatments for

human leukemias.

Predisposing factors

The exact cause of leukemia is unknown, although many genetic and environmental factors are

involved in its development. The basic mechanism involves damage to genes controlling cell

growth. This damage then changes cells from a normal to a malignant (cancer) state. Analysis of

bone marrow of a client with acute leukemias shows abnormal chromosomes about 50% of the

time. Possible risk factors for the development of leukemia include ionizing radiation, exposure

to chemicals and drugs, bone marrow hypoplasia (reduced production of blood cells), genetic

factors, immunologic factors, environmental factors, and the interaction of these factors.

Ionizing radiation exposures such as radiation therapy for cancer treatment or environmental

irradiation increase the risk for leukemia development, particularly acute myelogenous leukemia

(AML).

Certain chemicals and drugs have been linked to the development of leukemia because of their

ability to damage DNA. Previous treatment for cancer that included melphaplan, cyclosphamide,
doxorubicin, and etoposide poses risks for leukemia development about 5 to 8 years after

treatment.

Bone marrow hypoplasia can increase leukemia risk by reducing or changing bone marrow cell

production. Disorders that have marrow hypoplasia and may lead to leukemia development

include Fanconi’s anemia, paroxysmal nocturnal hemoglobinuria, and myelodysplastic

syndromes.

Genetic factors influence leukemia development. There is an increased incidence of the disease

among clients with hereditary conditions such as Down syndrome, blooms syndrome, Klinefelter

syndrome, and Fanconi’s anemia. Identical sibling’s of client with leukemia have a higher rate of

leukemia than does general population.

Immunologic factors, especially immune deficiencies, may promote the development of

leukemia. Leukemia among immunodeficient people may be a result of immune surveilance

failure, or the same mechanisms that cause the immune deficiency may also trigger cancer in the

white blood cells population.

Interaction of many host and environmental factors may result in leukemia. Because each person

tolerates the interaction of these factors differently, it is difficult to determine the origin of any

specific leukemia.

Bone Marrow
 Bone marrow is the flexible tissue found in the hollow interior of bones. In adults,

marrow in large bones produces new blood cells. It constitutes 4% of total body weight, i.e.

approximately 2.6 kg (5.7 lbs.) in adults.

There are two types of bone marrow: red marrow consisting mainly of hematopoietic

tissue and yellow marrow consisting mainly of fat cells. Red blood cells, platelets and most

white blood cells arise in red marrow. Both types of bone marrow contain numerous blood

vessels and capillaries.

At birth, all bone marrow is red. With age, more and more of it is converted to the yellow

type. About half of adult bone marrow is red. Red marrow is found mainly in the flat bones, such

as the hip bone, breast bone, skull, ribs, vertebrae and shoulder blades, and in the cancellous

material at the epiphyseal ends of the long bones such as the femur and humerus. Yellow marrow

is found in the hollow interior of the middle portion of long bones.

 In cases of severe blood loss, the body can convert yellow marrow back to red marrow to

increase blood cell production.

Bone marrow barrier

The blood vessels constitute a barrier, inhibiting immature blood cells from leaving the bone

marrow. Only mature blood cells contain the membrane proteins required to attach to and pass

the blood vessel endothelium.

Hematopoietic stem cells may also cross the bone marrow barrier, and may thus be harvested

from blood .

Stem Cells

Many of the blood cells that comprise the bloodstream within the arteries and veins are

born and mature within the bone marrow. They are derived from hematopoietic cells that are

called stem cells. Stem cells within the bone marrow continuously divide to form new cells.

Some of the new cells remain unchanged as stem cells and have a lifelong capacity for

self-renewal. These cells are called pluripotential cells. Other, unipotential stem cells have a

limited capacity for self-renewal. Also known as progenitor cells, unipotential cells become

committed to forming only one type of blood cell line erythrocytes, leukocytes , or platelets.

Colonies of progenitor cells provide offspring of increasing differentiation or maturity.

They react to specific compounds known as poietins. Poietins stimulate the progenitor cells until

they transform into the appropriate young blood cell known as a "blast" cell.
 Although stem cells are few in number composing no more than 3% to 5% of all cells in

the marrow they are the only cells capable of producing the progenitor cells that eventually form

all of the blood elements. The number of blood cells produced every day is enormous. In adults,

blood cell production amounts to about 2.5 billion erythrocytes, 2.5 billion platelets, and 1.0

billion granulocytes per kilogram of body weight.

Types of stem cells

Bone marrow contains three types of stem cells.. Hematopoietic stem cells give rise to the

three classes of blood cells that are found in the circulation, white blood cells, red blood cells and

platelets . Mesenchymal stem cells are found arrayed around the central sinus in the bone

marrow. They have the capability to differentiate into osteoblasts, chondrocytes, myocytes, and

many other types of cells. They also function as "gatekeeper" cells of the bone marrow. Another

type is the Endothelial stem cells.

 Blood Cells

The main cells of the blood are red blood cells or RBCs, white blood cells or WBCs and

platelets.

Precursor proerythroblasts (pronormoblast, normoblast, or rubriblast) produce

erythroglasts. Erythroglasts produce reticulocytes. After about four days of differentiation and

hemoglobin production, the erythroglast sheds its nucleus and becomes a reticulocyte. After

spending two more days in the bone marrow, the reticulocyte enters the circulation where,

twenty-four hours later, they complete their maturation and become indistinguishable from other

mature RBCs. An elevated reticulocyte count indicates bleeding. Normal range is from 0-1.5%.

Red blood cells (RBCs)

erythrocytes have no nuclei, and consist mainly of hemoglobin in a supporting

framework called stroma. RBC formation takes place in the red bone marrow of the adult and in
the liver, spleen, and bone marrow of the fetus. This formation requires ample supplies of such

dietary elements as iron, cobalt, copper, amino acids, and certain vitamins.

main function of RBCs is to transport oxygen and carbon dioxide as well as the

maintenance of a normal acid/base balance. Since they also help to determine the viscosity (a

tendency to resist flow) of the blood, RBCs influence its specific gravity.

During its 120-day life span, an RBC makes about 75,000 round trips between the lungs

and tissues. At the end of its life, it returns to the bone marrow where it is removed by the

reticuloendothelial system particularly the liver, bone marrow, and spleen. Despite the constant

destruction and production of RBCs about 300 billion are destroyed and replaced each day, the

body is able to maintain a fairly constant number. A decreased number usually indicates some

form of anemia.

Whiteblood cells (WBCs)

WBCs are also known as leukocytes (leuko meaning white and cyte meaning cell). Their

lifespan averages 13-21 days after which they are destroyed by the lymphatic system. Their

numbers change with age and during pregnancy. During the first two weeks after birth, WBC

numbers will be high.

WBCs are classified according to whether or not they have granules in their cytoplasm.

Those that contain granules are called granulocytes and those that do not have granules are called

agranulocytes.
There are five different types of WBCs.

Granulocytes

Myeloblasts are the immature and most primitive precursor of granulocytes. Myeloblasts

are cells of the bone marrow not normally found in peripheral blood. They develop into

promyelocytes (progranulocytes) which go on to produce the three cell types collectively known

as granulocytes. Granulocytes were consist of:

Basophils make up less than 1% of the WBCs and are somewhat smaller than other

granulocytes. Their main functions are to release histamine and to play a primary role in the

inflammatory response. Basophils migrate to sites of injury, crossing the capillary endothelium

to accumulate within damaged tissues where they discharge their granules into the interstitial

fluids. These granules release heparin, an anticoagulant, which stops the bleeding and begins the

process of tissue repair. Because basophils are found in large numbers in areas where there are
larger amounts of blood, as in the lungs and liver, the release of heparin is thought to reduce the

formation of tiny blood clots. Other chemicals released by the stimulated basophils attract

eosinophils and other basophils to the area, thereby reducing inflammation more quickly.

Neutrophils make up 50-70% of the circulating WBCs. The name indicates that they are

chemically neutral and thus difficult to stain with either an acid or base dye. A mature neutrophil

has a very dense, contorted nucleus that may be condensed into a series of lobes resembling

beads on a chain.

Neutrophils are known by many names. Because the nucleus of a neutrophil can have

many shapes and sizes, it is often referred to as a polymorph or simply, polys. For the same

reason, neutrophils are also called "polymorphonuclear leukocytes" or PMNs. Neutrophils are

referred to as segs when the nucleus appears segmented or having many lobes. Sometimes, they

are called band cells because the immature neutrophil looks like a thick, curved band. If the band

resembles a staff, the cells are then called staff cells or stab cells (from the German word

meaning "staff").

No matter what they are called, the function of a neutrophil is to engulf pathogens or

debris in damaged or infected tissues. They can survive minutes or days, depending on the tissue

activity; but the average life span is about ten to twelve hours. After engulfing up to two dozen

bacteria, for example, a neutrophil dies. Its breakdown releases chemicals that attract other

neutrophils to the site to carry on where it left off. The collection of dead neutrophils, cell parts,

and fluid left at a site of infection is called pus.

Eosinophils make up about 1-3% of the total WBCs. They are so named because their

granules darkly stain an orange-pink with the red dye eosin. Although they are phagocytes,
eosinophils generally ignore bacteria and cellular debris and, instead, are attracted to foreign

compounds that have reacted with circulating antibodies. They are involved in dissolving clots

and in the inflammatory response, secreting chemicals that destroy certain parasites. Their

numbers also increase during allergy attacks. Microphages are neutrophils and eosinophils,

which are small enough to enter peripheral tissues when there is an injury or infection.

Agranulocytes

Lymphocytes are usually the most important and the most numerous of the

agranulocytes, making up about 20-25% of the WBCs. Until the age of about eight years,

lymphocytes are more predominant than neutrophils. Pregnancy will also cause a slight rise in

lymphocytes.

Lymphocytes are often identified as being small, medium, or large, with the large ones found

mainly outside the circulation in lymphatic organs and thus the name. Involved in immune

responses, lymphocytes are further divided into T and B lymphocytes: T-cells for cell-mediated

immune reactions and B-cells for humoral immunity. Morphologically, they are

indistinguishable. Differences can only be seen by serological tests. During staining, the nucleus

will be very densely stained with the cell appearing round but sometimes with a very slight

indentation. The cytoplasm is a thin band to one side of the nucleus, and is stained a dusky blue

color.

Monocytes are larger than lymphocytes and have a kidney-shaped nucleus. Monocytes

make up about 4-8% of the total WBC population. They function as phagocytes and develop into

macrophages. The nucleus varies in shape: kidney-shaped, bean-shaped, or horseshoe-shaped,

with a deep indentation. Monocytes do not stain as deeply as lymphocytes do.

Platelets

Platelets are developed through the following process:

Megakaryoblasts produce megakaryocytes which produce platelets (thrombocytes).

Platelets are the tiniest formed elements of the blood. Normally, each microliter of blood

contains between 150,000 and 450,000 platelets. A platelet is not a complete cell, but a fragment

of the megakaryocyte, which develops fissures in its cytoplasm and literally falls apart. Even

though a platelet does not contain DNA or a nucleus, it does contain a cytoplasm with

mitochondria and various enzymes surrounded by a cell membrane. Platelets have a life span of

5-9 days.

Responsible for initiating the clotting process, their only function is to prevent blood loss

from injured blood vessels. Failure of the bone marrow to replace platelets at an adequate rate

results in a deficiency called thrombocytopenia, which is characterized by pinpoint hemorrhages

under the skin (petechiae) and abnormal bleeding episodes

Importance of White Blood Cells

 White blood cells (WBCs), or leukocytes (also spelled "leucocytes"), are cells of the

immune system defending the body against both infectious disease and foreign materials. Five[1]

different and diverse types of leukocytes exist, but they are all produced and derived from a

multipotent cell in the bone marrow known as a hematopoietic stem cell. Leukocytes are found

throughout the body, including the blood and lymphatic system.

The number of WBCs in the blood is often an indicator of disease. There are normally

between 4×109 and 1.1×1010 white blood cells in a litre of blood, making up approximately 1% of

blood in a healthy adult. An increase in the number of leukocytes over the upper limits is called

leukocytosis, and a decrease below the lower limit is called leukopenia. The physical properties

of leukocytes, such as volume, conductivity, and granularity, may change due to activation, the

presence of immature cells, or the presence of malignant leukocytes in leukemia.

Lymphocyte

Lymphocytes are much more common in the lymphatic system. Lymphocytes are

distinguished by having a deeply staining nucleus which may be eccentric in location, and a

relatively small amount of cytoplasm. The blood has three types of lymphocytes.

B cellsB cells make antibodies that bind to pathogens to enable their destruction. (B cells

not only make antibodies that bind to pathogens, but after an attack, some B cells will retain the

ability to produce an antibody to serve as a 'memory' system.)

T cells which is consist ofCD4+ helper T cells co-ordinate the immune response and are

important in the defense against intracellular bacteria. In acute HIV infection, these T cells are
 [9]
the main index to identify the individual's immune system activity. Research has shown that

CD8+ cells are also another index to identify human's immune activity.

CD8+ cytotoxic T cells are able to kill virus-infected and tumor cells.

T cells possess an alternative T cell receptor as opposed to CD4+ and CD8+ αβ T cells

and share characteristics of helper T cells, cytotoxic T cells and natural killer cells.

Natural killer cells are able to kill cells of the body which are displaying a signal to kill

them, as they have been infected by a virus or have become cancerous.

Human stem cells differentiate into several kinds of blood cell within the bone

marrow.This process is called haematopoiesis. All lymphocytes originate, during this process,

from a common lymphoid progenitor before differentiating into their distinct lymphocyte types.

The differentiation of lymphocytes follows various pathways in a hierarchical fashion as well as

in a more plastic fashion. The formation of lymphocytes is known as lymphopoiesis. B cells

mature into B lymphocytes in the bone marrow, while T cells migrate to and mature in a distinct

organ, called the thymus. Following maturation, the lymphocytes enter the circulation and

peripheral lymphoid organs e.g. the spleen and lymph nodes where they survey for invading

pathogens and or tumor cells.

 Genetic, Environmental,
Idiopathic (radiation)

Acute lymphocytic Leukemia

Overproduction of immature
White Blood Cells

Integumentary Respiratory Gastro Intestinal Musculoskeletal Central Nervous Hematologic

System
Decrease Abnormal WBC
Excessive WBC
Decrease Crowding out of Increase no. of production
accumulating in infiltrating in
erythrocyte WBC accumulationof RBC
Production of RBC bone marrow CNS
in liver and spleen Headache
Decrease O2 Disorientatio
Anemia Decrease O2 Increase Pressure
supply SpleenomegalyHepatomegal n
supply
y
Pallor of Hypoxia Fatigue and
skin and Malaise Bone/ Joint
Abdominal Abdominal Pain
mucous Pain
distention Lymphatic
membrane Dyspnea
Weaknes
s
Feeling of Proliferation of Excessive
Tachycar fullness immature non accumulating in
dia functioning cellslymph node
Anorexia/ Loss
of apetite Decrease lymphadenop
defense against
infection
Weight Neutropenia Decrease
Fev
decrease RBCplatelet count

Anemia Thrombocytop
enia
Bruising
and
PATHOPHYSIOLOGY
 LABORATORY

Specimen Source 8-15-10

blood
TEST OF EXAMINATION REQUESTED
Retics Count
RESULT

Results: 1.0 %
(NV.: 0.50-1.5 %)

EXAMINATION RESULT
FBS
BUN 3.2-7.3 mmol/l 5.10
Creatinine 80-115umol/l 101.1
Cholesterol
Uric Acid
SGOT M 10-50 U/L 55.5
F
SGPT M 10-50 U/L 33.5
F
Alk. Phosphatase
Triglycerides

EXAMINATIONS RESULTS
HEMOGLOBIN
Male 140-180 g/L 137
Female 120-160 g/L
HEMATOCRIT
Male 0.40-0.54 Liter 0.40
Female 0.37-0.47 Liter
WBC COUNT 5.0-10.0x109/L 79.3
DIFFERENTIAL COUNT
Segmenters 0.55-0.75 0.20
Stab 0.02-0.08
Lymphocytes 0.20-0.35 0.58
Monocytes 0.02-0.06 0.04
IMMATURE CELLS 0.18
Myelocytes 0
Basophils 0-0.01
Platelet-145,000/ul

Hematology report 8-27-10

EXAMINATION RESULTS EXAMINATIONS RESULTS

HEMOGLOBIN RED BLOOD
CELL (RBC)
Male 140-180 100 Male 4.5-6.0 x 10 3.4
g/L 12/L
Female 120-160g/L Female 4.0-5.0xJ10
12/L
HEMATOCRIT PLATELET Adequate
150,000-350,000/uL
Male 0.40-0.54 0.30 RETICULOCYTES
Liter CT.
Female 0.37-0.47 ESR
Liter (WESTERGREN
METHOD)
WBC COUNT 5.0- 25.7 x 10 9/L Male 0-
10.0X10 9/L 15mm/Hr
DIFFERENTIAL Female 0-
COUNT 20mm/Hr
Segmenters 0.55- 0.30 COAGULATION
0.75 TIME
Stab 0.02-0.08 Slide Method 3-5
minutes
Lymphocytes 0.20- 0.67 BLEEDING TIME
0.35 1-3 minutes
Monocytes 0.02- l.E PREP.
0.06
Eosinophils BLOOD TYPING
0.01.0.03
Juveniles 0-0.01 RH TYPING
Blast Cells 0.03
Basophils 0-0.01
Hemmatology report 9-4-10

Parameter Value
Wbc (5.5-10.0) 30.8 10^9/J
LYM %( 15-20) 25.0 %
GRA %(35-80) 43.0 %
MID %/ BLAST CELLS(2-15) 32.0 %
HCT(43.5-53.7) 27.0 %
HGB(14-18) 9.0 g/dl
MCH (27-32) 30.30
MCHC(32-36) 33.70 G/DL
RBC(4.38-5.13) 2.54 10^12/J
MCV(80-100) 89.8 fl
PLT(150-390) ADEQUATE 10^9/j
Xray report 8-15-10

There’s a homogenous density noted in the right lower lobe. There are air bornchogram. The
heart is not enlarged. The diaphragm and the rest of findings are normal.

IMPRESSION LOWER LOBE: PROBABLE LOBAR CONSOLIDATION, RIGHT SUGGEST

LATERAL VIEW

XRAY REPORT 8-17-10

ADDITIONAL LATERAL VIEW SHOW THE PRESENCE OF CONSOLIDATION IN THE

RIGHT LOWER LOBE

Urinalysis report

Results Microscope:
Color Appearance Yellow/sl. Turbid Pus cells: 1-4/hpf
Reaction Acidic RBC: 0-2/hpf
Specific gravity 1.015 Epithelial Cells:
Albumin(Qual) Negative Amorphous:
Sugar (Qual) Negative Mucuc Threads: few
Occult Blood Bacteria:
Acetone Casts:
Bile
Urobilinogen
Other tests

8-16-10

Specimen Examination Desired

Blood Peripheral blood smear

-marked leukocytosis with shift to the left

-isolated nucleated Red Blood Cells and few Myelocytes
- platelets moderately diminished
-smears suggestive of an acute inflammatory process of non-specific
type

NOTE: please refer to hematologist for definite impression.

8-16-10 hematology

EXAMINATION RESULTS EXAMINATIONS RESULTS

HEMOGLOBIN RED BLOOD
CELL (RBC)
Male 140-180 Male 4.5-6.0 x 10 3.4
g/L 12/L
Female 120-160g/L Female 4.0-5.0xJ10
12/L
HEMATOCRIT PLATELET Adequate
150,000-350,000/uL
Male 0.40-0.54 RETICULOCYTES
Liter CT.
Female 0.37-0.47 ESR
Liter (WESTERGREN
METHOD)
WBC COUNT 5.0- Male 0-
10.0X10 9/L 15mm/Hr
DIFFERENTIAL Female 0-
COUNT 20mm/Hr
Segmenters 0.55- 0.60 COAGULATION
0.75 TIME
Stab 0.02-0.08 0.23 Slide Method 3-5
minutes
Lymphocytes 0.20- BLEEDING TIME
0.35 1-3 minutes
Monocytes 0.02- 0.10 l.E PREP.
0.06
Eosinophils BLOOD TYPING
0.01.0.03
Nucleated RBC’s 0.01 RH TYPING
Myelocytes 0 0.06
Basophils 0-0.01
 DISCHARGE PLAN

M- Medication

Take Home medication as prescribed by the physician

-Prednisone

-Purinethol

E- Environment

> Environment should have proper sanitation and ___ from any accidental hazards and

infection.

> Instruct the significant to others that the client should be in a well-ventilated, free from

infection and room temperature environment.

- Instruct the patient to avoid exposure to large doses of radiation

- Instruct patient to avoid exposure to benzene and other chemicals

- Home care management is improving; care can be as comprehensive as one might

need on receive in the hospital setting

T- Treatment

- Regular check-ups that schedule for the client

 - Follow the prescribed diagnostic tests of the client especially the CBC and lumbar

Puncture for the condition of the bone marrow

The client will undergo certain therapies for further recovery of the patient as prescribed

of the doctor.

• Induction therapy that begun and last for 4-6 weeks that achieves a complete

remission or less than 5% leukemic cells in the bone marrow.

• CNS Prophylactic Therapy to prevent leukemic cells from invading the CNS

• Intensification/ Consolidation Therapy to eradicates residual leukemia cells

followed by delayed intensification that prevents emergence of resistant leukemic

cells.

• Maintenance Therapy that serves to maintain the remission phase, CBC are taken

to evaluate the bone marrows response to drugs.

H- Health Teachings

• Instruct the client to perform ambulation and tolerable exercises

• Encourage the client to increase fluid intake to lessen the side effects of

medications and to prevent dehydration.

• Encourage the patient to participate in health teaching for continuous recovery

and to ensure proper understanding and response.

• Inform the significant others to give psychological and emotional support to client

to lessen the anxiety of the client.

• Promote adequate physical and mental rest

 • Inform the significant others to report immediately any obvious signs of adverse

effects of the medications taken or any complication during home care.

• Teach the client as well as the significant others that the environment should be

well-ventilated, room temperature and well clean to be free from infection that

client may receive.

• Instruct the client/ significant others that hygiene is very important such as

practicing hand washing every time and wearing mask to prevent of transmitting

the infection.

O- Observable Signs and Symptoms

• Observe for any signs and symptoms of infection such as fever and inflammation.

• Instruct the client and significant others to report immediately for excessive

bleeding.

• Notify the physician immediately if there is any adverse effects/ reactions of the

medication

D- Diet

• Encourage the client to increase intake of high fiber and protein

• Instruct the client to increase fluid intake

• Diet as tolerated but follow cautiously a healthy meal