Introduction Leukemia is a cancer of the blood, and is characterized by uncontrolled proliferation and accumulation of leukocytes (white blood cells).

Most leukemic cells never mature into functioning leukocytes. Where in the body is 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. There many different types of leukemia but the four most important forms are derived from only two types of cells, lymphocytes and myelocytes. Acute myelogenous leukemia is disorders of granulocytes. Granulocytes produced by bone marrow, engulf and digest bacteria and other small particles. This generally appears suddenly with symptoms like those of cold, and progresses rapidly. The lymph nodes, spleen and liver may become infiltrated with leukocytes and enlarged. There is often 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 hemorrhaging and uncontrolled infections. Acute myelogenous leukemia occurs much less frequently in children. A. Definition of terms Acute myelogenous leukemia (AML) is a cancer of the blood and bone marrow the spongy tissue inside bones where blood cells are made. Granulocytes produced by bone marrow, engulf and digest bacteria and other small particles.

I.

History Taking a. Biological Information Name: Mr. Abella, Fernando Age: 50 years old Sex: Male Birthday: August 28,1962 Birth place: Bongabon, Nueva Ecija Civil Status: Married Address: Santor Bongabon, Nueva Ecija Phone Number: 09269018766 Educational attainment: High school graduate Occupation: farmer Race or ethnic background: Religion: Catholic Nationality: Filipino

i. ii. iii. iv. v. vi. vii. viii. ix. x. xi. xii. xiii.

xiv. xv.

Language spoken: tagalog Source of information: wife b. Chief Complaints: Tonsilitis/fever

i. ii.

Initial Diagnosis: Acute Myelogenous Leukemia Final Diagnosis: Acute Myelogenous Leukemia

c. History of Present illness: 6 days PTA d. Past medical history

i. ii. iii. iv. v. vi. vii.

(+)fever

Problem at birth: none Childhood illnesses: 9ys/old chicken pox

e. Family medical history i. f. ROS SKIN, HAIR & NAILS Skin o Are you experiencing any current skin problem? NO o Have you noticed any change in your ability to feel pain, pressure, light touch, or temperature changes? YES o Do you have trouble controlling body odor? NONE Head and neck o Have you had any change in the condition of your hair? NONE o Have you had any change in the condition or appearance of your nails?

g. Lifestyle and Health practices i. Nutritional Metabolic Pattern

Before the patient was not admitted in the hospital, he likes to eat any kind of foods. But as of now, the patient does not want to eat and he vomits all the time. The patient drinks alcohol mostly every day, he prefers to drink Tanduay and Emperador. The patient also smokes and can consume one pack per day.. According to the patient his weight had decreased from 180 pounds to 110 pounds. ii. Activity or Exercise Pattern

Before, the patient used to walk from his home to his office, but now even five steps he feels fatigue and will have a difficulty in breathing. The patient was advised by the physician not to over fatigue himself and he needs enough sleep and rest. iii. Sleep or rest Pattern

Before the patients hospitalization, he sleeps at 7: 00 pm to 6:00 in the morning, but now because of his condition he sleeps most of the time. The patient has no problem in sleeping. iv. Medication, supplements and substances use

The patient takes vitamin supplements like Revicon and Everet v. Self Perception Pattern

The patient is concerned about his illness. He is scared that he will die and might be far away from his family. According to the patient, he wants to be free from Leukemia but it is too impossible to happen, it needs some miracles. The patient describes himself as very religious especially with his condition and he must need some faith to hold on to whatever circumstances might happen. His condition made him different because unlike normal people he needs to wear a mask all the time. vi. Value or belief System The patient is a Roman Catholic and God is very important to him. For him, God and his family is his source of strength and meaning. The patient prays the rosary and attends mass every Sunday. The patient wishes to go to Simala to pray for his condition. According to the patient, he just accepts what Gods plan awaits him. vii. Coping or stress Tolerance Pattern

The patient and his wife both make the decision especially when it comes to health and financial matters. He sometimes seeks help to his mother when it comes t o problem solving because he is

more comfortable in asking for assistance so that he can express his feelings. The patient is still working but he will just go to work to punch in and leave. h. Developmental Level The patient belongs to the middle adulthood. The middle years, from 40 65, have been called the years of stability and consolidation. For most people, it is a time when children have grown and moved away or are moving away from home. Thus, partners generally have more time for and with each other and time to pursue interests they may have deferred for years. The middle adulthood, the individual makes lasting contributions through involvement with others. During this period, personal and career achievements have often already been experienced. Many middle adults find particular joy in assisting their children and other young people to become productive and responsible adults. They may also begin to help aging parents. Using leisure time in satisfying and creative ways is a challenge that, if met satisfactory, enables middle adults to prepare for retirement. Men and women must adjust to inevitable biological changes. As in adolescence, middle adults use considerable energy to adapt self concept and body image to physiological realities and changes in physical appearance. High self-esteem, a favorable body image, and a positive attitude toward physiological changes are fostered when adults engage in physical exercise, balanced diet, adequate sleep, and good hygiene practices that promote vigorous, healthy bodies. Physical Changes A number of changes take place during the middle years. At 40, most adults can function as they did in their twenties. However during ages 40 65, many physical changes takes place. Both men and women experience decreasing hormonal production during the middle years. The menopause refers to the so called change of life in women, when menstruation ceases. It is said to have occurred when a woman has not had a menstrual period within a year. The menopause usually occurs anywhere between ages 40 55. The average is about 47 years. At this time, the ovaries decrease in activity until ovulation ceases. Psychologically, the menopause can be anxiety- producing time, especially if the ability to bear children is an integral part of womans self concept. The hair begins to thin and gray hair appears. Skin turgor and moisture decrease, subcutaneous fat decreases and wrinkling occur. Fatty tissue is redistributed, resulting in fat deposits in the abdominal area. Skeletal muscle bulk decreases at about age 60. Thinning of the intervertebral disk causes a decrease in height of about 1 inch. Calcium loss from bone tissue is more common among postmenopausal women. Muscle growth continues in proportion to use. Blood vessels lose elasticity and become thicker. Visual acuity declines, often by the late forties, especially for near vision (presbyopia). Auditory acuity for high- frequency sounds (presbycusis) also decreases, particularly in men. Taste sensations also diminish. Metabolism slows, resulting in weight gain. Gradual decrease in tone of large intestine may predispose the individual to constipation. Nephron units are lost during this time, and glomerular filtration rate decreases. Hormonal changes take place in both men and women.

Cognitive Changes The middle- aged adults cognitive and intellectual abilities change very little. Cognitive processes include the action time, memory, perception, learning, problem solving, and creativity. Reaction time during the middle years stays much the same or diminishes during the later part of the middle years. Memory and problem solving are maintained through middle adulthood. Learning continuous and cab be enhanced by increased motivation at this time in life. Middle-aged adults are able to carry out all the strategies described in Piagets phase of formal operations. The experiences of the professional, social, and personal life of middle-aged persons will be reflected in their cognitive performance. Thus, approaches to problem solving and task completion will vary considerably in middle-aged group. The middle-aged adult can reflect on the past and current experience and can imagine, anticipate, plan and hope. Changes in the cognitive function of middle adults are rare except with illness are trauma. The middle adult can learn new skills and information. Some middle adults enter educational or vocational programs to prepare themselves for entering the job market or changing jobs.

Moral Changes During this stage, rules and laws are valued because they maintain social order worth preserving. Morality is guided by higher principles of human conduct. Individuals appreciate the social purposes served by laws. They believe laws should be derived from a democratic consensus. Individuals search their own conscience for universal ethical principles. They do not make up their own rules but instead arrive at abstract principles that all religions or moral authorities might view as compelling or fair. There is a correlation between higher stages of reasoning and higher levels of moral behavior. According to Kohlberg, the adult can move beyond the conventional level to the post conventional level. Kohlberg believes that extensive experience of personal moral choice and responsibility is required before people can reach the post conventional level. Kohlberg found that few of his subjects achieved the highest level of moral reasoning. Psychosocial Development The psychosocial changes in the middle adult may involve expected events, such as marital separation. This change may result in stress that can affect the middle adults over all level of health. In the middle adult years, as children depart from the household, the family enters the post parental family stage. Time and financial demands on the parents decrease, and the couple faces the task of redefining their own relationship. According to Eriksons developmental theory, the primary developmental task of the middle years is to achieve generativity. Generativity is the willingness to care for and guide others. If middle adults fail to achieve generativity, Stagnation occurs. This is shown by excessive concern with themselves or destructive behavior toward their children and community. Spiritual Changes

As man grows older he becomes more aware of the outside world. Some conform when they are forced to do so, some are driven by self interests and will do only what they must do to get what they want in return. They violate Gods law regularly, sinning more or less everyday with little remorse. Their spiritual senses are not alert. They are ignorant of God and have no concept of holiness. But as man grows older, he becomes more conscious of how important people really are. Being good is now important. He thinks about how other people see him and how they must feel. He realizes that the world runs according to rules. The desire to please other drives him and when he fails his first response is to justify himself. This faith is based on the beliefs of the community. In adult life many individuals develop a faith that is purely their own individual faith and can deal with the paradoxes and ironies of human existence. A final stage of development finds some individuals making a commitment to universal values, such as love and justice. The focus on the value of experience and reflection and intellectual development finds a strong parallel in the importance given to the rule of experience and reflection in spiritual growth.

Sexuality Changes After the departure of their last child from the home, many couples recultivate their relationships and find increased marital and sexual satisfaction during middle age. The onset of menopause and the climacteric can affect the sexual satisfaction during the middle adult. Other factors influencing sexuality during this period include work stress, diminished health of one or both partners, and the use of prescription medications. II. Collecting objective data

a. Course of confinement i. Medications administered since date of admission Physicians order Generic Name Brand Name Classification Mechanism of action Side effects 1. 2. Nsg. Mgt. 1. 2.

3.

3.

Adverse Effects 1. 2. 3.

Nsg. Mgt. 1. 2. 3.

Physicians order Generic Name Brand Name Classification Mechanism of action Side effects 1. 2. 3. Nsg. Mgt. 1. 2. 3.

Adverse Effects 1. 2. 3.

Nsg. Mgt. 1. 2. 3.

Physicians order Generic Name Brand Name

Classification Mechanism of action Side effects 1. 2. 3. Nsg. Mgt. 1. 2. 3.

Adverse Effects 1. 2. 3.

Nsg. Mgt. 1. 2. 3.

Physicians order Generic Name Brand Name Classification Mechanism of action Side effects 1. 2. 3. Nsg. Mgt. 1. 2. 3.

Adverse Effects 1. 2. 3.

Nsg. Mgt. 1. 2. 3.

Physicians order Generic Name Brand Name Classification Mechanism of action Side effects 1. 2. 3. Nsg. Mgt. 1. 2. 3.

Adverse Effects 1. 2. 3.

Nsg. Mgt. 1. 2. 3.

ii.

Other parenteral medication Intravenous fluids ordered Previous IVF Rationale

1. 2. Current IVF 3. To follow IVF 4. 5. Rationale Rationale

iii. Diagnostic Test Hemoglobin Hematocrit

Diagnostic tests Result 6.77gm/dL 19.3 Normal Value 14-17.5gm/dL 14-17.5 Significance Decreased: Anemia Increased: Erythrocytosis

WBC Band Segmenter Basophil Eosnophil Lymphocyte

174,000 02% 05% --07%

4.4-11.0 3% 56% 0.3% 2.7% 34%

Increased: Infection Decreased: Decreased: NORMAL NORMAL Decreased: Immuno

Monocyte

61%

4%

deficiency Increased: Viral

RBC MCV MCH

1.93 10 12/L 100fL

4.5-5.9 10 12/L 80-96fL

infections Decreased: Anemia Increased: Macrocytic

35.1 pg

27.5-33.2pg

Anemia Increased: : Macrocytic Anemia

MCHC MPV RDW Platelet Count

35.0% --27,020/cu mm

33.4-35.5% --150,000-450,000/cu mm NORMAL NORMAL NORMAL Decreased: Acute Leukemia

Reticulocyte ESR --0.5-1.5%

Creatinine Serum Potassium ALT Sodium 2.1 mg/dL 3.0 mmol/L 59 uL 134 mmol/L Uric Acid 11.9 mg/L

0.00-20.00mm/h 0.7-1.5mg/dL 3.6-5.0mmol/L 11-66uL 137-145mmol/L

NORMAL NORMAL Increased: Fever Decreased: Diarrhea NORMAL

2.5-7.5mg/L

Decreased: Metabolic Acidosis Increased: Gout

- Red blood cells carry oxygen throughout the body. Low numbers can lead to anemia feeling tired or weak, being short of breath and looking pale.

- Platelets control bleeding. Low numbers can lead to easy bleeding or bruising and tiny red spots under the skin (petechiae).

b. Physical Assessment i.General Impression Cyanotic Pale Weak in appearance

ii.ht, wt. and vital signs temperature- 36.5 degree Celsius pulse rate- 60 bpm Increased RR- 26 bpm BP-90/60 mmhg 58

iii.skin cyanosis, extremely cool iv.Neurologic- Conscious, coherent

Body Parts

Inspection

Palpation

Percussion

Auscultation

HEAD

Round in shape Normocepahlic Evenly distributed, Black in color, short, straight hair, smooth No dandruff Presence of pimples noted, No wrinkles, brown in color Round, brown in color, No wrinkles, pimples noted Black in color, no lesions noted

No tenderness No Lumps

HAIR

SCALP FACE

No Lumps noted

FOREHEAD

No Lumps noted

EYEBROWS

EYELIDS

EYELASHES

No Lumps Closes and opens noted without difficulty No Mass noted Equally distributed Pale, moist

CONJUNCTIVA SCLERA Opaque in color, moist PUPIL Pupil equally round reactive to light and accommodation, Constricts and dilates IRIS Dark brown in color

LACRIMAL Pale, no discharges EXTRAOCULAR EYE Moves without MOVEMENT any difficulty, follows the six cardinal gaze LIPS Pale in color, symmetrical MOUTH Gums are pale, fair in size, dry TONGUE Pinkish in color, whitish palate present TEETH Yellowish with a complete set of teeth PALATE Hard and soft palate are pale in color UVULA Rises upon saying ah, medially located TONSILS Pale in color NOSE Has discharges, nasal mucus noted, centrally located, not patent, septum located medially, no lesions, nasal flaring was not EARS noted Symmetrical, ear wax noted, can hear clearly, auricle aligned

No mass noted

No mass noted

with outer canthus NECK Brown in color, symmetrical, can perform ROM exercises, lymph nodes are not inflamed SKIN Brown in color, petechiae was noted in both lower and upper extremities (pin point like appearance), Temperature of 36.8 degree Celsius EXTREMITIES: UPPER: Without IV, can perform limited ROM exercises, petechiae was noted (pin point like appearance) CHEST Equal chest expansion RR: 24 breaths per minute HEART

Carotid pulse: 78 beats per minute, no lumps noted

BP: 90/60 mmhg Clear breath sounds Bowel sounds: 3 upon auscultation

Vibration felt upon tactile fermitus

LUNGS ABDOMEN Brown in color, no abdominal distention LOWER: Can perform limited ROM

exercises, presence of petechiae (pinpoint like appearance) on his both legs

III.

List of NANDA

List of Prioritized Nsg.Dx. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

IV.

PATHOPHYSIOLOGY