Case Mr. Abella, Fernando, 60 yrs.

Old, male, Filipino Roman Catholic, Study:

who is married and has four children, all of which are still schooling. The patient works in a government office. The patient is always exposed in petroleum products and paints. Mr. Abella is not hypertensive, diabetic and asthmatic. He is an occasional drinker and a positive smoker which he consumes one pack per day. Mr. Abella was rushed in the emergency room of Cebu Doctors University Hospital because he fainted and was very pale. He also complains of tonsillitis. The results of the blood test reveals Hgb 6.77gm/dl, Hct 19.3, WBC 174,000, Platelet count 27,020/cu mm.

CASE STUDY:
Acute Myeloid Leukemia (AML)

Prepared by: Lyka MARIE Avila Kristian COCO Pacheco

Acute Myeloid Leukemia (AML)

Also known as Acute Myelogenous Leukemia or Acute Nonlymphocytic Leukemia (ANLL)

A cancer of the myeloid line of blood cells, characterized by the rapid growth of abnormal white blood cells that accumulate in the bone marrow and interfere with the production of normal blood cells. AML is the most common acute leukemia affecting adults, and its incidence increases with age. Although AML is a relatively rare disease, accounting for approximately 1.2% of cancer deaths in the United States, its incidence is expected to increase as the population ages.
The symptoms of AML are caused by replacement of normal bone marrow with leukemic cells, which causes a drop in red blood cells, platelets, and normal white blood cells. These symptoms include fatigue, shortness of breath, easy bruising and bleeding, and increased risk of infection. Several risk factors and chromosomal abnormalities have been identified, but the specific cause is not clear. As an acute leukemia, AML progresses rapidly and is typically fatal within weeks or months if left untreated.

 AML has several subtypes; treatment and prognosis varies among subtypes. Five-year survival varies from 1570%, and relapse rate varies from 3378%, depending on subtype. AML is treated initially with chemotherapy aimed at inducing a remission; patients may go on to receive additional chemotherapy or a hematopoietic stem cell transplant. Recent research into the genetics of AML has resulted in the availability of tests that can predict which drug or drugs may work best for a particular patient, as well as how long that patient is likely to survive

Signs And Symptoms

Most signs and symptoms of AML are caused by the replacement of normal blood cells with leukemic cells. A lack of normal white blood cell production makes the patient susceptible to infections; while the leukemic cells themselves are derived from white blood cell precursors, they have no infection-fighting capacity. A drop in red blood cell count (anemia) can cause fatigue, paleness, and shortness of breath. A lack of platelets can lead to easy bruising or bleeding with minor trauma.

Diffusely swollen gums due to infiltration by leukemic cells in a person with acute myelomonocytic leukemia

The early signs of AML are often vague and nonspecific, and may be similar to those of influenza or other common illnesses. Some generalized symptoms include fever, fatigue, weight loss or loss of appetite, shortness of breath, anemia, easy bruising or bleeding, petechiae (flat, pin-head sized spots under the skin caused by bleeding), bone and joint pain, and persistent or frequent infections.

Enlargement of the spleen may occur in AML, but it is typically mild and asymptomatic. Lymph node swelling is rare in AML, in contrast to acute lymphoblastic leukemia. The skin is involved about 10% of the time in the form of leukemia cutis. Rarely, Sweet's syndrome, a paraneoplasticinflammation of the skin, can occur with AML.

Diagnostic
If a patients presents with the symptoms of acute myeloid leukemia a battery of tests are ordered. The tests used to diagnose AML include the following.

Blood tests
First a complete blood count is prescribed. Anemia is commonly detected with haemoglobin levels usually less than 5g/dl. In addition there is thrombocytopenia of varying degrees. This means there is a low platelet count. White blood cell (WBC) count is usually high but may be normal or low. The number of neutrophils is usually low. When a small sample of blood is smeared onto a glass slide and examined under the microscope there may be presence of blast cells. This is called peripheral blood smear. The blood smear may be normal if the blast cells are confined to the bone marrow. Blood clotting is tested by checking elevated prothrombin time, reduced fibrinogen level and the presence of fibrin degradation products. Lactic dehydrogenase levels may be raised in blood. In addition due to increased number of cell death and formation there may be raised uric acid levels. Liver and renal function is checked especially before administering chemotherapy. In case of infections blood cultures and other appropriate tests may be prescribed.

Bone marrow biopsy

In case of an abnormal blood test, bone marrow biopsy is prescribed. The biopsy involves taking a sample of bone marrow using a syringe. The needle is pierced into the hip bone commonly and a sample is drawn. The procedure is painful and performed under a local anesthetic. The procedure takes around 15 minutes to complete and is performed on an outpatient basis. The sample of bone marrow is checked for cancerous cells and abnormal cells. The cells are also checked to see the type of leukemia.

Lumbar puncture or spinal tap

Lumbar puncture involves taking a small sample of cerebrospinal fluid from the spinal column and checking for presence of abnormal cancer cells. This may be positive in patients in whom the cancer has spread to the central nervous system. A lumbar puncture is not often used to test for AML, unless the patient has symptoms that the leukemia has affected the central nervous system. A lumbar puncture is sometimes used to deliver chemotherapy drugs into the CSF.

Cell examination
Samples of blood, bone marrow, or CSF are looked at under a microscope to check the size, shape, and other traits of the white blood cells. This helps in classifying the type of AML.

The percentage of cells in the bone marrow or blood that are blasts is particularly important. Having at least 20% blasts in the marrow or blood is generally required for a diagnosis of AML. It can also be diagnosed if the blasts have a chromosome change that can be seen in specific types of AML even if the blast percentage does not reach 20%. Sometimes the blasts look similar to normal immature cells in the bone marrow. However, in normal bone marrow the blast count is 5% or less. In order for a patient to be considered to be in remission after treatment, the blast percentage in the bone marrow must be less than 5%.

Cytochemistry
These tests include staining the leukemia cells with special dyes. For example, some of these stains cause the granules of most AML cells to appear as black spots under the microscope, but it does not cause ALL cells to change color. This helps in differentiating between the cancers.

CT Scan and Imaging Studies

Those with AML may need to undergo imaging studies like MRI scans and CT scans to check for spread to major organs like heart, lungs, brain and liver.

Those with AML may need to undergo imaging studies like MRI scans and CT scans to check for spread to major organs like heart, lungs, brain and liver.

Flow cytometry and immunohistochemistry

This helps in assessing the cells from the bone marrow and blood samples. These tests are helpful in determining the exact type of leukemia.

A sample of cells is treated with special antibodies that stick to the cells only if their specific protein is present on the cell surfaces. The cells are then passed in front of a laser beam. The laser light gives off light from the cells that have antibodies attached to them.
The computer can measure the number and nature of these cells. In immunohistochemistry tests blood and bone marrow samples are treated with specific antibodies so that cancer cells with proteins that bind to these antibodies change color and are visible under the microscope. These tests are used for immunophenotyping.

Cytogenetics
This involves identifying the genetic blueprints of the cancer cells. The leukemia cells atypical genetic makeup that can be identified using these tests. Identifications of the genetic abnormalities help in determining treatment. One of the common errors or genetic mutations includes translocations. This means part of one chromosome may be replaced by part of another. Recognizing these changes can help identify certain types of AML and predict the possible outcome of the cancer. Common translocation include t(8;21) meaning part of chromosome 8 is now located on chromosome 21, and vice versa. Another type of error is inversion where a segment is reversed in alignment. For example, inv(16) means that part of the chromosome 16 is upside down. Deletion, addition and duplication are other forms of errors.

Fluorescent in situ hybridization (FISH)

This is similar to cytogenetic testing. This technique uses fluorescent dyes that only attach to specific parts of particular chromosomes. Once tagged to the chromosomes they are visible under a microscope in standard cytogenetic tests. FISH can be used to look for specific changes in chromosomes. It can be used on blood or bone marrow samples.

Polymerase chain reaction (PCR)

This is yet another DNA analysis test that can find some chromosome changes too small to be seen under a microscope.

LABORATORY TEST
DIAGNOSTIC TEST Hemoglobin NORMAL VALUE 14 -17.5 gm/dl RESULT 6.77 gm/dl SIGNIFICANCE Decreased: Anemia Increased Erythrocytosis Increased: Infection Decreased: Acute Leukemia

Hematocrit

14 - 17.5

19.3

WBC

4.4 - 11.0

174,000

Platelet Count

450,000 / cu mm

27,020 / cu mm

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

NURSING INTERVENTIONS

RATIONALE

EVALUATION

Subjective: Objective: - pale in appearance - weakness - shortness of breath - low hemoglobin count: 6.77

Activity Intolerance: fatigue related to anemia.

After nursing intervention the patient will be able to demonstrate a decrease in physiologic signs of intolerance.

1. Monitor Vital Signs. 2. Elevate head of bed as tolerated. 3. Encourage quiet, restful atmosphere. 4. Instruct patient to stop activity if palpitations, chest pains, shortness of breath, weakness, dizziness occur. 5. Demonstrate/ encourage use of relaxation activities, exercises/ techniques.

1. Serves as baseline data. 2. To promote circulation/ venous drainage. 3. Conserves energy/ lowers tissue Oxygen demand. 4. To lessen the work of the heart. 5. To decrease tension level.

After nursing intervention the patient shows a decrease signs of intolerance.

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

NURSING INTERVENTIONS

RATIONALE

EVALUATION

Subjective: Objective: - increased WBC:174,000 - presence of immature leukocytes - compromised immunity -low platelet count: 27, 020 cu mm

Risk for infection related to proliferation of immature lymphocytes.

After nursing intervention the client will be free from acquiring infection.

1. Monitor Vital Signs. 2. Instruct patient to wear mask all the time. 3. Require good hand washing protocol for all personnel and visitors. 4. Monitor Temperature. Note correlation between temperature elevations and chemotherapy treatments. 5. Inspect skin for tender, erythematous areas; open wounds cleanse skin with antibacterial solution.

1. Serves as baseline After nursing data. intervention 2. Protect patient from the client was potential sources of able to be free pathogens/ infection. from acquiring 3.Prevents crossinfection. contamination/reduces risk for infection. 4. Although fever may accompany some forms of chemotherapy, progressive hyperthermia occurs in some types of infections, and fever (unrelated to drugs or blood products) occurs in most leukemia patients.

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

NURSING INTERVENTIONS

RATIONALE

EVALUATION

6. Coordinate Procedures and test to allow for interrupted rest periods. 7. Avoid/ limit invasive procedures (e.g., venipuncture and injections) as possible. 8. Administer medication as indicated by physician.

5. May indicate local infection Note; Open wounds may not produce pus because of insufficient number of granulocyte. 6. Conserves energy for healing, cellular regeneration. 7. Break in skin could provide an entry for pathogenic/ potentially lethal organisms. Use of central venous lines (e.g., tunneled catheter or implanted port) can effectively reduce need for frequent invasive procedures and risk of infection. 8. May be given prophylactically or treat specific infection.