CLL report

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Institute Of Nursing SY: 2011-2012 NCM 106A “CHRONIC LYMPHOCYTIC LEUKEMIA” Group 2 - BSN 209 ALMARIO, Ryneil M. DE PANO, Ana Maria Christina F. GALMO, Marielle Erika G. PARGUIAN, Rhyss William M. RODRIGUEZ, Jack TAN, Glen Richard A. Submitted to: MA ’ AM SUSAN ROMERO Clinical Instructor

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WHAT IS LEUKEMIA? Leukemia is a disease that affects blood-forming cells in the body. It is a cancerous condition characterized by an abundance of abnormal white blood cells in the body. Leukemia begins in the bone marrow and spreads to other parts of the body. Both children and adults can develop leukemia . TYPES OF LEUKEMIA There are several different types of leukemia . In general, leukemia is grouped by how fast it gets worse and what kind of white blood cell it affects. It may be acute or chronic . Acute leukemia gets worse very fast and may make you feel sick right away. Chronic leukemia gets worse slowly and may not cause symptoms for years. It may be lymphocytic or myelogenous . Lymphocytic (or lymphoblastic) leukemia affects white blood cells called lymphocytes. Myelogenous leukemia affects white blood cells called myelocytes . The four main types of leukemia are: Acute lymphoblastic leukemia , or ALL. Acute myelogenous leukemia , or AML. Chronic lymphocytic leukemia , or CLL. Chronic myelogenous leukemia , or CML. In adults, chronic lymphocytic leukemia (CLL) and acute myelogenous leukemia (AML) are the most common leukemias . In children, the most common leukemia is acute lymphoblastic leukemia (ALL). Childhood leukemias also include acute myelogenous leukemia (AML) and other myeloid leukemias , such as chronic myelogenous leukemia (CML) and juvenile myelomonocytic leukemia (JMML).

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CHRONIC LYMPHOCYTIC LEUKEMIA Chronic lymphocytic leukemia (chronic lymphoid leukemia ) is a monoclonal disorder characterized by a progressive accumulation of functionally incompetent lymphocytes .

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What Are the Signs and Symptoms of CLL? It is often discovered when changes in the blood show up during a routine medical check up. These are some of the tests used to diagnose CLL: In the early stages of CLL,, the leukemia cells function almost normally, and CLL symptoms may not appear for a long time. Doctors will often find chronic lymphocytic leukemia during a routine checkup , before there are any symptoms. When symptoms do appear, they are generally mild at first and progress gradually. Common CLL symptoms include: Painless swelling of the lymph nodes in the neck, underarm, stomach, or groin Feeling very tired Pain or fullness below the ribs Fever and infection Weight loss for no known reason

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DIAGNOSTIC TESTS Blood cell counts: Checks lymphocyte (the cells that fight infection) levels. People with CLL have a high lymphocyte count and/or a low red blood cell and platelet count. Blood cell examination: Examines CLL cells to determine if CLL is the reason for the high lymphocyte count. Immunoglobulin test: Checks the blood for immunoglobulin, the proteins that help the body fight infection. Fluorescence in situ hybridization (FISH): Tests to see if there are changes to the chromosomes of the CLL cells. Bone marrow biopsy: Examines bone marrow for abnormalities. This test provides a baseline used later for assessing the effects of treatment.

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- PATHOPHYSIOLOGY

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PREDISPOSING FACTORS: Age Heredity CHRONIC LYMPHOCYTIC LEUKEMIA Etiology Unknown Failure of B-cells to mature to plasma cells that synthesize hypogammaglobulinemia Accumulation of Malignant B-cells in the Marrow B-cells become resistant to Apoptosis Infiltration of abnormal cells to other organs of the body Interruption of proper organ functioning DEATH Suppressed Immune system Increased Susceptibility to Infection

CASE STUDY   Mr. C.K., a 72-year-old retired Air Force jet mechanic, was diagnosed with chronic lymphocytic leukemia. He went to the physician 10 days after his initial cycle of chemotherapy. He complained of mild chills and vomiting for two days. And was also experiencing severe pain and when asked to rate it, with 1 being the least painful and 10 being the most painful, he answered it as 9. The patient also reported that he notices occasional bruising.   Upon physical examination, the patient had a temperature of 38.3°C and appeared pale and weak. He described feeling as if he had the flu. Cardiac examination demonstrated a tachycardia with an accelerated pulse of 110bpm with a respiratory rate of 20cpm and blood pressure of 110/80mmHg. There was generalized weakness and alterations in muscle tone. Abdominal examination revealed palpable liver and spleen which indicated possible enlargement. Lymph node examination demonstrated an enlargement in the left submandibular nodes (approximately 4cm) and supraclavicular nodes (left>right, 1-2cm).   The nurse observed that the patient manifests fatigue and facial grimacing. He also demonstrated protective gestures during palpation and seemed irritated. : 

CASE STUDY Mr. C.K., a 72-year-old retired Air Force jet mechanic, was diagnosed with chronic lymphocytic leukemia . He went to the physician 10 days after his initial cycle of chemotherapy. He complained of mild chills and vomiting for two days. And was also experiencing severe pain and when asked to rate it, with 1 being the least painful and 10 being the most painful, he answered it as 9. The patient also reported that he notices occasional bruising. Upon physical examination, the patient had a temperature of 38.3°C and appeared pale and weak. He described feeling as if he had the flu. Cardiac examination demonstrated a tachycardia with an accelerated pulse of 110bpm with a respiratory rate of 20cpm and blood pressure of 110/80mmHg. There was generalized weakness and alterations in muscle tone. Abdominal examination revealed palpable liver and spleen which indicated possible enlargement. Lymph node examination demonstrated an enlargement in the left submandibular nodes (approximately 4cm) and supraclavicular nodes (left>right, 1-2cm). The nurse observed that the patient manifests fatigue and facial grimacing. He also demonstrated protective gestures during palpation and seemed irritated.

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- PROBLEM PRIORITIZATION

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NURSING DIAGNOSIS RANK JUSTIFICATION Acute pain related to physical agents, such as enlarged organs and lymph nodes, and chemical agents, such as the antileukemic treatments. 1 Acute pain is health threatening and an actual problem. It has the highest priority because the problem needs immediate intervention and continued evaluation to reduce patient discomfort. It is a high priority because the knowledge and skills of the nurse are available to modify the problem. Then, the cooperation, time and money of the client are also available to help manage the problem. Risk for infection related to inadequate primary defenses . 2 Risk for infection is a potential problem. Treatment of the 2 nd priority problem as the problem needs immediate intervention and a careful evaluation. This problem will be prevented or reduced together with the highest priority problem. Knowledge and skills of the nurse are helpful to prevent the occurrence of the problem. Then, the cooperation and time of the client are important for health teaching.

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NURSING DIAGNOSIS RANK JUSTIFICATION Risk for deficient fluid volume related to vomiting 3 Risk for deficient fluid volume is a potential problem. The p roblem doesn’t require immediate interventions as it is only a potential problem and treating this will prevent further complications. Knowledge and skills of the nurse are helpful to prevent the occurrence of the problem. Then, the cooperation and time of the client are important for health teaching.

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NURSING CARE PLAN

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ASSESSMENT NURSING DIAGNOSIS GOALS AND OBJECTIVES INTERVENTION RATIONALE EVALUATION SUBJECTIVES: The patient reported experiencing severe pain and rated it as 9 (10 being the most painful and 1 being the least painful). He described feeling as if he had the flu. OBJECTIVES: Facial grimacing Alterations in muscle tone Fatigue Generalized weakness Enlarged lymph nodes Enlarged spleen and liver V/S taken as follows: T: 38.3 P: 110 R: 20 BP: 110/80 Acute pain related to physical agents as manifested by protective gestures and facial mask of pain. GOALS: After 6 days of nursing intervention, the patient will verbalize minimized or controlled feeling of pain . OBJECTIVES: After 8-hours of nursing interaction, the patient will be able to: Identify the characteristics of the pain he is experiencing demonstrate use of relaxation methods Apply the lessons learned during the nursing interaction. INDEPENDENT : Monitor vital signs and note nonverbal cues, such as muscle tension and restlessness. Acknowledge the pain experience and convey patient’s response to pain. Provide quiet environment and reduce stressful stimuli. Teach the use of non-pharmacologic techniques before, after, and if possible during painful activities; before pain occurs or increases; and along with other pain relief measures . Alterations from normal may be signs of infection. Observations may/may not be congruent with verbal reports or may be only indicator present when patient is unable to verbalize. Pain is a subjective experience and cannot be felt by others . Promotes rest and enhances coping abilities . The use of noninvasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications .. After 6 days of nursing interventions, the patient is able demonstrate use of relaxation techniques to reduce pain and is able to verbalize controlled feeling of pain.

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ASSESSMENT NURSING DIAGNOSIS GOALS AND OBJECTIVES INTERVENTION RATIONALE EVALUATION Place in position of comfort, and support joints and extremities with pillows and other padding Reposition periodically and provide or assist with gentle range of motion. COLLABORATIVE: Administer pain medications as indicated May decrease associated bone and joint discomfort . Improves tissue circulation and joint discomfort . To help reduce pain experienced.

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ASSESSMENT NURSING DIAGNOSIS GOALS AND OBJECTIVES INTERVENTION RATIONALE EVALUATION SUBJECTIVE: The patient reported experiencing occasional bruising and described feeling as if he had the flu. OBJECTIVE: Appeared pale and weak Irritable Facial grimacing Fatigue V/S taken as follows: T: 38.3°C P: 110 R: 20 BP: 110/80 Risk for infection related to inadequate primary defences. GOALS: After a complete nursing intervention the client will be able to demonstrate understanding and behaviours about the disease and to prevent developing the problem . OBJECTIVES: After 30 minutes of nursing intervention, the client will be able to identify actions to prevent or reduce possibility of infection. INDEPENDENT: Assess for presence, existence of, and history of risk factors such as open wounds and abrasions Limit visitors as indicated. Restrict fresh fruits and vegetables or make sure they are washed or peeled. Monitor the following for signs of infection: Redness, swelling, increased pain or drainage. Require good handwashing protocol for all personnel and visitors. Represent a break in the body’s normal first lines of defence. Protect patient from potential sources of pathogens or infection. Any suspicious drainage should be cultured; antibiotic therapy is determined by pathogens identified at culture. Prevents cross contamination or reduce risk for infection. After 8 hours of nursing interventions the patient was able to identify actions to prevent or reduce the risk for infection

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ASSESSMENT NURSING DIAGNOSIS GOALS AND OBJECTIVES INTERVENTION RATIONALE EVALUATION Encourage frequent turning and deep breathing. Handle patient gently. Keep linens dry or wrinkle free. Inspect skin for tender, erythematous areas, open wounds. Cleanse skin with antibacterial solutions. Inspect oral mucous membranes. Provide good oral hygiene. Use a soft toothbrush, sponge, or swabs for frequent mouth care. Coordinate procedures and tests to allow for uninterrupted rest periods. COLLABORATIVE: Prepare for or assist patient with leukemia treatments such as chemotherapy, radiation, and bone marrow transplantation. Administer antibiotics as indicated. Prevents stasis of respiratory secretions, reducing risk of atelectasis or pneumonia. Prevents sheet burn or skin excoriation. May indicate local infection. The oral cavity is an excellent medium for growth of organism and is susceptible to ulceration and bleeding. Conserves energy for healing, cellular regeneration. Leukemia is usually treated with a combination of these agents, each requiring specific safety precautions for patient and care providers. May be given prophylactically or to treat specific infection.

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ASSESSMENT NURSING DIAGNOSIS GOALS AND OBJECTIVES INTERVENTION RATIONALE EVALUATION SUBJECTIVE: The patient complained of mild chills and vomiting for two days. OBJECTIVES: Facial mask of pain Appeared pale and weak V/S taken as follows: T: 38.3 P: 110 R: 20 BP: 100/80 Risk for deficient fluid volume related to vomiting. GOALS: After 8 hours of nursing interventions, the patient will maintain adequate fluid volume as evidence by moist membranes, good skin turgor , and capillary refill . OBJECTIVES: After 30 minutes of nursing intervention, the patient will be able to demonstrate behaviours to monitor intake and output. INDEPENDENT : Monitor intake and output Assess vital signs. Blood pressure, pulse and temperature . Observe for excessively dry skin and mucus membranes, decreased skin turgor , slowed capillary refill. Note generalized muscle weakness or cardiac dysrhythmias . COLLABORATIVE: Administer antiemetics as indicated. Provides information about overall fluid balance as well as guidelines for fluid replacement. Hypotension, tachycardia, fever can indicate response to/and affect of fluid loss. Indicates excessive fluid loss or resultant dehydration . Excessive intestinal loss may lead to electrolyte imbalances . Used to control nausea and vomiting. After 8 hours of nursing interventions, the patient was able to maintain adequate fluid volume as evidenced by moist mucous membranes, good skin turgor and capillary refill.