MYELOID LEUKEMIA

CASE PRESENTATION
DEMOGRAPHIC

 This is the case of B, K., 23-year-old female, single, Roman

Catholic, born on October 5, 1995 in San Fabian,
Pangasinan, currently residing in the same locality,
admitted for the second time in this institution on May 8,
2019. The patient is the informant herself with a percent
reliability of 90%.
 Chief Complaint: For Blood Transfusion
HISTORY OF PRESENT ILLNESS

 The patient is a known case of

Acute Myeloid Leukemia
one month prior to admission
confirmed via bone marrow
biopsy. Patient was admitted at
this time and has undergone first
cycle chemotherapy and blood
transfusions. Patient was
discharged improved.
HISTORY OF PRESENT ILLNESS

 Interval history revealed persistence of

occasional productive cough, whitish in
color, 1 teaspoon in amount, blood-tinged
with associated on and off fever,
undocumented, temporarily relieved by
paracetamol
 . Patient had regular follow-up with her private
oncologist. The patient was maintained on the
following medications: Iron 1 tab BID, Cefexime 1
tab BID, and Omeprazole OD pre-BF.
HISTORY OF PRESENT ILLNESS

 Two days prior to admission,

patient underwent a repeat
complete blood count which
revealed
thrombocytopenia hence
was referred to this
institution for blood
transfusion and was
subsequently admitted.
PAST MEDICAL HISTORY

 She claimed that she was

diagnosed with erythema
nodosum and was treated with
prednisone.
 The patient noted pruritus when
mefenamic acid was taken.
FAMILY HISTORY

 There was paternal

history of multiple
myeloma and lung
cancer
SOCIAL AND ENVIRONMENTAL HISTORY

 Patient works in a courier company.

She lives with her 3 other siblings.
Patient is a non-smoker and non-
alcoholic beverage drinker. Patient eats
a balanced meal of vegetables and meat.
Patient lives in a well-ventilated, non-
congested concrete house. Drinking
water is from a refilling station while
water for general use is from local
water distributor.
PATHOPHYSIOLOGY
 PROBLEM PRIORITIZATION
Problem Prioritization
Acute joint pain related to This is the priority problem because this is an actual problem
periosteal irritation secondary to that the client is experiencing. According to Kolcaba’s
AML comfort theory, pain is one of the major cause why a patient
has a disturbance in comfort. When the patient is in pain,
he/she is not cooperative with any therapeutic regimen that
the healthcare team is providing. Alleviating the pain is
needed so that the patient will return to his/her functional
level. Kolcaba (2003) also stated that since pain is a subjective
feeling, nurses should provide a holistic approach to address
the pain. If this problem will not be resolved, chances that the
patient will not be receptive to any interventions which may
worsen the present condition.
Excess fluid volume related to
compromised regulatory mechanism
Activity intolerance r/t presence of
joint paint
This is the 2nd priority problem because it is an actual
problem of the patient. Due to her condition, AML, the
kidneys are also affected in which she cannot excrete
waste products and there is an edema of both upper and
lower extremities. According to Maslow’s hierarchy of
needs, physiologic needs must be fulfilled first in order to
achieve the succeeding needs of a person.
This is the 3rd priority problem because this is brought about the
previously mentioned problems. According to Maslow’s hierarchy
of needs, activity is one of the physiology needs that the individual
must achieve. It was stated by Olson (1990) that physical mobility
has a drastic effect on the cardiovascular and respiratory function
of an individual which extends to weakening and atrophy of
muscles. The reason why the patient is having a difficult time to
move is because of the pain associated with his condition which is
AML and effect of the chemotherapy.
Impaired skin integrity related to
presence of bruises secondary to AML
This is the 4th priority problem because it is an actual
problem of the patient. The patient has bruises that are
evident brought about by low platelet count. According to
Maslow’s Hierarchy of needs, blood as a part of fluids is
one of the physiologic need to maintain adequate and
normal circulation in the body. Blood is very important
because it carries oxygen to tissues, supplies nutrients in
the body, aids in metabolism, transports hormones and
remove water (Menche, 2012). Due to low platelet count,
the patient’s blood will have difficulty in clotting thus
hematoma is present. If there will be bleeding, there will
be a problem with circulation and patient may lead to
shock.
Disturbed body image r/t
biophysical illness secondary to
effect of chemotherapy
Risk for bleeding
This is the last priority problem since the problem
is still manageable but cannot be modified because
of the effect of chemotherapy. This problem if
cannot be managed, must be towards the
acceptance of the patient regarding her illness state
and the effects of her treatment. According to
Maslow’s Hierarchy of Needs, self-esteem and body
image must be accepted and met to gain fulfillment
of this need.
This is the 6th priority problem because this is a potential
problem brought about by her disease. According to
Maslow’s Hierarchy of needs, blood as a part of fluids is one
of the physiologic need to maintain adequate and normal
circulation in the body. Blood is very important because it
carries oxygen to tissues, supplies nutrients in the body,
aids in metabolism, transports hormones and remove water
(Menche, 2012). If there will be bleeding, there will be a
problem with circulation and patient may lead to shock.
 NURSING CARE PLAN # 1: ACUTE JOINT PAIN RELATED TO PERIOSTEAL
IRRITATION SECONDARY TO ACUTE MYELOID LEUKEMIA

CUES
Subjective:
“Masakit yung mga kasukasuan ko.”

Objective:
Pain rated as 7/10 characterized as throbbing localized on
the joints aggravated by movement and pressure which is
relived by rest and alleviated by medications.
O> Appeared to be weak. Grimaces and sighing behavior
noted. With complaints of joint pain and weakness. Needs
partial assistance in doing ADLs.. Vital signs of: BP: 100/60
mmHg, PR: 123 bpm, RR: 25 cpm, T: 36.7C, SpO2: 93%.
NURSING CARE PLAN # 1: ACUTE JOINT PAIN RELATED TO PERIOSTEAL
IRRITATION SECONDARY TO ACUTE MYELOID LEUKEMIA

Explanation of the
Problem
NURSING CARE PLAN # 1: ACUTE JOINT PAIN RELATED TO PERIOSTEAL
IRRITATION SECONDARY TO ACUTE MYELOID LEUKEMIA

GOALS AND OBJECTIVES

Goal: Relief of pain
STO:
Within 2 hours of nursing intervention, the patient will
report relieve or controlled pain as manifested by
normal vital signs and absence of grimacing pain rating
less than 3/10.
LTO:
Within 3 days of nursing intervention, patient will be
able to do relaxation and diversional activities to
decrease pain such as music therapy, conversing, and
promotion of quiet environment which is conducive for
rest as non-pharmacologic ways to manage pain.
NURSING CARE PLAN # 1: ACUTE JOINT PAIN RELATED TO PERIOSTEAL
IRRITATION SECONDARY TO ACUTE MYELOID LEUKEMIA

INTERVENTIONS
 Assessed pain characteristics (PQRST)  Administered pain medications as ordered.

 Assessed and noted for non-verbal cues and behavior. • Tramadol

 Assessed and monitored changes of vital signs,  Instructed to try to engage in guided imagery.

 Determined clients acceptable levels of pain and pain  Encouraged to verbalize feelings of pain or any care
control goals. concerns.

 Provided rest periods to promote relief, sleep, and  Encouraged to have adequate rest periods.
relaxation.  Instructed to report any improvement or exacerbation
 Provided comfort measures such as repositioning, restful in pain experience
and quiet environment.
 Elicit behaviors that are conditioned to promote
relaxation such as abdominal breathing thru the mouth.
NURSING CARE PLAN # 1: ACUTE JOINT PAIN RELATED TO PERIOSTEAL
IRRITATION SECONDARY TO ACUTE MYELOID LEUKEMIA

EVALUATION CRITERIA
STO:
 Fully met if pain rate will be 0-3/10 from 7/10.
 Partially met if pain rate will be 4-6/10 from 7/10.
 Not met if pain rate will be 7-10/10.
LTO:
 Fully met if patient is able to do all 3 non-pharmacologic management for pain as stated in the goals and objectives.
 Partially met if patient is only able to do 1-2 non-pharmacologic management for pain.
 Not met if patient is not able to do any non-pharmacologic management for pain.
NURSING CARE PLAN # 2: EXCESS FLUID VOLUME R/T
COMPROMISED REGULATORY MECHANISM SECONDARY TO AKI
CUES
 Subjective:
“umiinom naman ako pero di ako umiihi” as verbalized.

 Objective:
With pitting edema +2 on extremities
Appears restless
U.O. in 7-3 shift is 0ml.

 Labs:
Hematology: as of 5/13/19 Hct= 0.24 (N: 0.37-0.47) and Hgb=
80 (N: 120-160)
Serum electrolytes: as of 5/14/19 Urea Nitrogen=
48.20md/dL (N: 8-23)
NURSING CARE PLAN # 2: EXCESS FLUID VOLUME R/T
COMPROMISED REGULATORY MECHANISM SECONDARY TO AKI

Explanation of the Problem

NURSING CARE PLAN # 2: EXCESS FLUID VOLUME R/T
COMPROMISED REGULATORY MECHANISM SECONDARY TO AKI

GOALS AND OBJECTIVES

Goal: : Balance fluid volume
STO:
 Within 8 hours of nursing interventions, the patient will:
Have UO of greater than or equal to 30ml/hr
Maintain BP of 90/60-120/80mmhg
Cooperate in interventions to help reduce edema
Maintain intact skin
LTO:
 Within 3 days of nursing interventions, the patient will manifest:
Improvement in fluid volume by balanced I&O
Decreased signs of edema
NURSING CARE PLAN # 2: EXCESS FLUID VOLUME R/T
COMPROMISED REGULATORY MECHANISM SECONDARY TO AKI

INTERVENTIONS Collaborative:
 Limit sodium intake as prescribed
Diagnostics:
 Collaborate with dietician to give patient less sodium
 Monitor vital signs especially BP and HR
foods
 Monitor urine output daily
Educative:
 Assess presence, location, and degree of edema
 Instruct patient and family members regarding fluid
 Review lab results (urea nitrogen and hematology)
restrictions as ordere
Therapeutic
 Educate patient and family members regarding fluid
Independent: volume excess and it’s causes
 Elevate edematous extremities and handle with care  Instruct significant other to help in repositioning of
 Reposition every 2 hours patient’s extremities every 2 hours
 Instruct patient and family members on importance of
proper nutrition, hydration, and diet modification
NURSING CARE PLAN # 2: EXCESS FLUID VOLUME R/T
COMPROMISED REGULATORY MECHANISM SECONDARY TO AKI

EVALUATION CRITERIA  Have UO of less than 30ml/hr or none

 STO:  BP of more than 130/70mmHg
FULLY MET IF:  Does not cooperate in interventions to help reduce edema
 Within 8 hours of nursing interventions, the patient will:  Doesn’t maintain intact skin and with increasing grade of edema
 Have UO of greater than or equal to 30ml/hr  LTO:
 Maintain BP of 90/60-120/80mmHg FULLY MET IF:
 Cooperate in interventions to help reduce edema  Within 3 days of nursing interventions, the patient will manifest:
 Maintain intact skin  Improvement in fluid volume by balanced I&O
 Decreased signs of edema
PARTIALLY MET IF: PARTIALLY MET IF:
 Within 8 hours of nursing interventions, the patient will:  Within 3 days of nursing interventions, the patient will manifest:
 Have UO of less than 30ml/hr  Little improvement in fluid volume by balanced I&O
 BP of more than 130/70mmHg  Increasing signs of edema
 Cooperate in some interventions to help reduce edema NOT MET IF:
 Doesn’t maintain intact skin  Within 3 days of nursing interventions, the patient will manifest:
 No improvement in fluid volume by balanced I&O
Increasing signs of edema
NOT MET IF:
 Within 8 hours of nursing interventions, the patient will: