Acute Lymphocytic Leukemia

Case study presentation on Acute Lymphocytic leukemia

1. Case presentation on ‘ Acute Lymphocytic leukemia ’ Prepared by : Kalpana kawan Roll no. 06 BNS 3 rd year

2. General Objective At the end of this presentation, participants will be able to know about case study of Acute Leukemia

3. Specific Objectives At the end of this presentation, participants will able to know: History of the patient physical examination finding Developmental task of adolecence Diseases profiles : Acute Leukemia

4. Specific Objectives contd ….. Drugs Profile Nursing Theory application Nursing care plan Patient progress note Health education Plan discharge teaching What I learned from case study References

5. History B iodemographic data Name : Sandesh Sunuwar Age :15 years Sex : Male Education status : Literate (Class 9) Occupation : Student Religion : Hindu Name of Guardian : Jhapatmaya Sunuwar Relationship : Mother Address :Khijidenba-3, Okhaldhunga , provience no.1

6. History Contd …… Bed no : 16 Ward : Oncology Ward I.P No. : 659940 Date of admission : 2078/07/15 Provisional Diagnosis : Acute Leukemia Final diagnosis : Acute Leukemia Unit : Hematology Attending Doctor : Dr. Anjan Shrestha

7. History contd …….. C hief complaints Fever for 1 week Shortness of breath for 2 months Dizziness for 2 months Right hypochondrium region pain

8. History contd …….. P resent health history Past health history Prenatal and birth history Family history There is history of asthma to his grandfather since 7 year.

9. History Contd.. Family tree

10. History Contd.. Nutritional and dietary history Personal history Socio-economic and environment history Psycological history Health seeking behaviour

11. Physical examination Findings of Physical examination: Patient's general state of health seem tired, fatigue, Patient's vital signs are BP-100/60mmhg, pulse- 120/min,temperature-99.8 F,respiration-20/min, Spo 2 - 96% in room air Patient malnourish. Weight 50kg, height-168cm, BMI- 17.71 kg/m2 Head: Danddruff present, Old scar of cut injury present on head

12. Physical examination contd … Skin : pale His personal hygiene seem unsatisfactory. Poor hair hygiene Eye : left corneal opacity Ear : Wax present on inspection. Lips : Lip was dry and crack Abdomen: - 3cm long old scar present over left lumber region.

13. Developmental task of Adolecence SN According to book In my patient 1. Accepting one’s physique He accepts his own physique. He is comfort with how he look. 2. Accepting a masculine role He accepts his masculine role but is not practicing these days due to health condition. 3. Development of own identity He develops his own identity being a resposible member of his family and a good students in his school. 4. Establishing new relation with new mates of both sexes He is able to make new friendship with people of both sexes of his age. 7. Acceptance of and adjustment to certain groups. He accepts his transformation as an patient and is co-operative during hospitalization and different procedures 8. Achieving emotional independence from parents and other adults. He is emotionally independence from his parents and other adults.

14. Anatomical and physiological review of Bone marrow and Blood

15. Anatomy contd …. Bone marrow is a spongy substance found in the center of the bones  such as hip and thigh bones.

16. Anatomy contd …. T ypes of bone marrow: 2 types The are : R ed bone marrow, known as myeloid tissue, Y ellow bone marrow, known as fatty tissue.

17. Anatomy contd …. Bone marrow stem cells 2 types of stem cells: hematopoietic and mesenchymal Red bone marrow consists of a delicate, highly vascular fibrous tissue containing hematopoietic stem cells. These are blood-forming stem cells. Yellow bone marrow contains mesenchymal stem cells, or marrow stromal cells. These produce fat, cartilage, and bone.

18. Anatomy contd …. Blood cell formation

19. Anatomy contd …. Hematopoiesis The process of developing different blood cells from these stem cells is known as  hematopoiesis

20. Disease profile

21. Leukemia Definition Leukemia is a clonal m alignant neoplasm of the h ematopoietic stem cells charecterized by the proliferation of normal blood cells .

22. Defination contd … Leukemia is cancer of the body's blood-forming tissues, including the bone marrow and the lymphatic system . ( Basavanthapa , BT. 2015)

23. Classification Base on speed of disease development: Acute leukemia Chronic Leukemia Base on cell type Lymphocytic leukemia  Myelogenous or myeloid leukemia 

24. Classification contd ….. There are four major types of leukemia Acute lymphocytic leukemia (ALL )   Acute myeloid leukemia (AML ) Chronic lymphocytic leukemia (CLL ) Chronic myeloid leukemia ( CML)

25. Acute lymphocytic leukemia (ALL) Acute lymphocytic leukemia is also known as acute lymphoblastic leukemia or ALL. It result from an uncontrolled proliferation of immature cells ( lymphoblasts ) derived from the lymphoid stem cell . This is the most common type of leukemia in children and accounts for 15% in adults.

26. Epidemiology Acute lymphocytic leukemia is  more common in males  than in females Usually occur before 14 years of age. Peak incidence is between 2-9 years of age and in older adult .

27. Epidemiology contd.. The rate of new cases of acute lymphocytic leukemia was 1.8 per 100,000 men and women per year. The death rate was 0.4 per 100,000 men and women per year. Prevalenc : In 2018, there were an estimated 103,536 people living with acute lymphocytic leukemia in the United States. (Centers for diseases Control and Prevention, 2018)

28. Classification of ALL ALL is classified morphologically using  French-American-British(FAB), There is 3 subtype . ALL- L1 ALL- L2 ALL-L3 ( Burkitt’s leukemia)

29. Classification of ALL contd …. ALL –L1 Size- small Cytoplasm scanty basophilic N/C ratio- high Nuclear membrane- regular Nucleoli- invisible or indistinct

30. Classification of ALL contd …. 2. ALL-L2 Size of blast – Large and heterogenous Cytoplasm – moderate N/C ratio lower Nuclear membrane irregular with clefting Nucleoli- prominent, 1-2

31. Classification of ALL contd …. 3. ALL- L3 ( Burkitt’s leukemia) Size of blast- large and homogenous Cytoplasm- moderate and intensely basophilic N/C ratio – lower Nuclear membrane-regular Nucleoli- prominent, 1-2

32. Etiology and Risk factor according to book picture and patient SN According to Book In my patient 1. Exact cause is unknown Present 2. Genetic factors Absent 3. Over exposure to ionizing radiations and chemicals Absent 4. Congenital abnormalities: Down’s syndrome Absent 5. Infection Absent

33. Pathophysiology Accumulation . Due to the precipitating factors, immature, non-functioning WBCs appear to accumulate first in the tissue where they originate ( lymphocytes in lymph tissue, granulocytes in bone marrow). Infiltration . These immature WBCs then spill into the bloodstream and from there infiltrate other tissues. Malfunction . Eventually, this infiltration results in organ malfunction because of encroachment and hemorrhage.

34. Pathophysiology

35. Sign and symptoms according to book and patient SN According to Book In my patient 1 Fever Present 2 Pale skin Present 3 Anemia Present 4 Dizziness Present 5 Bleeding Absent 6 Anorexia Present 7 Fatigue Present 8 Weakness and feeling tired Present 9 Breathlessness Present 10 Bone, joint and abdominal pain Absent

36. Sign and symptoms contd …. SN According to book In my patient 11 Generalized lymphadenopathy, infection, weight loss Absent 12 Hepatomegaly Absent 13 Spleenomegaly Absent 14 Headache Absent 15 Mouthsores Absent 16 Pitting edema in the lower limbs and/or abdomen Absent 17 Increased ICP(nausea, vomiting, lethargy, cranial nerve dysfunction) Absent 18 Petechiae, which are tiny red spot or lines in the skin due to low plates levels. Absent 19 Testicular enlargement Absent

37. Diagnostic test of Acute Lymphocytic Leukemia SN According to book In my patient 1 History Done 2 Physical examination Done 3 Blood test: -Low RBC count, Hb , Hct - Low platelet count -Low , normal or high WBC count Done - RBC:2.31 million/cum -Platelets:79000/cu -TLC:3300/cum 4 Peripheral blood smear Done

38. Diagnostic test SN According to book In my patient 5 Bone marrow aspiration and biopsy Done 6 Imaging test: X-ray,CT scan, Ultrasound scan may help determine whether cancer has spread to the brain and spinal cord or other parts of the body. Done(USG of abdomen/ pelvis – minimal pelvic acites 7 Lumber puncture: The spinal fluid is tested to see whether cancer cells have spread to the spinal fluid. Done (report due)

39. Treatment Medical Management Chemotherapy Chemotherapy is the initial treatment of choice, and most people with ALL receive a combination of medications .

40. Treatment cont … Chemotherapy for ALL consists of three phases: Remission induction : Its aim to rapidly kill most tumor cells. Chemotherapy agent: steroids -  prednisolone or  dexamethasone vincristine asparaginase daunorubicin

41. Treatment cont … 2. I ntensification/Consolidation Given immediately after induction therapy for several months. Includes the same drugs as those used in induction but at higher dosages  to further reduce tumor burden.

42. Treatment cont … 3. Maintenance therapy . Treatment with lower doses of the same drugs used in induction or other drugs given every 3 to 4 weeks for a prolonged period of time. Chemotherapy agent: oral  mercaptopurine oral methotrexate vincristine and oral corticosteroids

43. Treatment cont … Biological therapy It is used to help the immune system to recognize and attack leukemia cells. Eg . Rituximab

44. Treatment cont … Targetted Therapy In targeted therapy, uses drugs that attacks the specific vulnerabilities within cancer cells . Eg . Imatinib .

45. Treatment cont … Radiation therapy Radiation therapy uses X-rays or other high energy beams to damage the leukemia cells and to stop their growth.

46. Treatment cont … Supportive management Cytopenias Transfusion support: Platelets and packed red cell transfusion when necessary. Prevention of Tumor Lysis Syndrome Intravenous hydration Allopurinol Correction of electrolyte disturbances( Hypocalcemia , hyperphosphatemia )

47. Treatment cont … Antibiotic prophylaxis Prophylaxis with antibiotics or antifungals during neutropenia. Acyclovir prophylaxis

48. Treatment cont … Surgical management Stem cell transplantation It is procedure to replace diseased bone marrow with healthy bone marrow.

49. Management done in my patient Chemotherapy 1 st Dose (2078/08/09) Inj.Dexona 10 mg IV Inj.Vincristine 1.5mg/m2 IV state Inj Daunorubicin 25 mg/m2 IV in 100ml NS IV over 30min 2 nd dose (2078/08/12) Inj L- Asparaginase 5000IU IM

50. Management done in my patient Supportive management Fresh Frozon Plasma Packed red cell trasfusion Iv fluid ( Inj Normal saline) Antibiotic and antifungal Isolation

51. Nursing management Assess the general condition of the patient. Closely monitor the lab value. Maintain good IPR with the patient. Provide psychological support. Instruct the patient to have a well balanced diet. Monitor vital signs  

52. Nursing management Include family members in providng care. Explain the side effects of chemotherapy Administer antibiotics. Maintain aseptic techniques while doing the procedures Proper isolation of the patient. Provide health education to the patient.

53. Complications Decreased resistance to infection Anemia Thrombocytopenia Bleeding tendency Infection Tumorlysis syndrome Mucositis Renal dysfunction Nutritional depletion Depression and anxiety

54. Prognosis Parameters Good Poor WBC Low High Gender Girls Boys Age Child Adult or infant Response to treatment Rapid <1 week to clear blasts from blood Slow >1 week to clear blasts from blood Time to remission <4 weeks >4 weeks Mediastinal mass Absent Present  

55. Drugs used in my patient Tab . Levofloxacin 750 gm PO Tab Bactrim DS P/O OD alternate day Tab Pantoprazole 40 mg PO OD Tab Flovin 5mg P/O OD Tab Fluconazole 150mg P/O BD Tab PCM 1 gram P/O SOS Tab warfarin 2 mg P/O OD

56. Application of nursing theory There are numbers of nursing theories and one of those theories is the self care deficit theory by Orem , which I have applied for my case study patient during my nursing care.

57. Nursing Process Assessment Obtain health history, focusing on fatigue, weight loss, night sweats, and activity intolerance. Assess for sign of bleeding and infection. Evaluate splenomegaly, lymphadenopathy and hepatomegaly . Assess the nutritional status. Assess vital signs. Assess respiratory status

58. Nursing Diagnosis Actual Nursing diagnosis Fatigue related to low hemoglobin levels. Increased body temperature related to potential for infection. Imbalance nutrition less than body requirements related to fatigue and anorexia. Anxiety related to knowledge deficit about disease process

59. Nursing Diagnosis contd …. Risk nursing diagnosis 5. Risk for infection related to neutropenia secondary to leukemia. 6 . Risk for deficient fluid volume and electrolyte imbalance related to potential for fever, sweating and use of antibiotics. 7 . Risk for impaired skin integrity related to toxic effects of chemotherapy.

60. Nursing Intervention Decreasing fatigue Reducing fever Nutrition Maintaining fluid and electrolyte balance Preventing and managing infection and bleeding Managing anxiety

61. Patient progress report

62. Health Education During Hospitalization Nutrition Physical care and maintenance of hygiene Rest and sleep Reporting Prevention of infection Family Support Protect skin integrity Side effect of chemotherapy

63. Discharge planning Nutrition Medication Hygiene maintainence , infection prevention Isolation Rest and exercise Complication PICC line care Injury/bleeding precaution Follow up care

64. What I learned from case study About the disease About the patient and his family About the nursing care Nursing theory application

65. References Basavanthapa , BT. (2015) Medical surgical nursing (3 rd ed ). Jaypee Brothers Medical Publisher(P)Ltd. Pageno.1024-1025 Ashalatha , PR. (2015) Textbook of anatomy and physiology for nurses (4 th ed ). Jaypee Brothers Medical Publisher(P)Ltd. Pageno.79-98 Black, J.M. Hawks, J.H. (2009) Medical surgical nursing (8 th ed ). Elsevier. Page no.2115-2120 Ameltzer , S.C. Bare, B. (2004) Brunner and suddarth’s m edical surgical nursing (10 th ed ). J.B. Lippincott company Pageno . 900-905

66. References contd … Hinkle, J. L. Cheever, K. H. (2015) Brunner and suddarth’s medical surgical nursing (13 th ed ). J.B. Lippincott company.page no.942-951 Retrive from Acute Lymphocytic Leukemia Nursing Care Management: Study Guide (nurseslabs.com ) on Nov 27, 2021 Gulanik M,(2003).Mosby’s Nursing Care Plan.(5 th edition). Mosby.page no.1019-1034. Adhikari . Raj Devi(2010), Nursing Theories and Models, 2 nd edition, Makalu house publication, ISBN:978-9937-503-25-9