Group 2

Giselle Turheis, age 38, is undergoing chemotherapy treatment for leukemia in the hospital. The staff has placed Mrs. Turheis on neutropenic precautions and restricted visitors to her room. The flowers she received from her family were sent home to avoid having standing water in her room. Healthcare workers regularly appear at her bedside in masks and gowns. When the nurse explains the reason for these precautions to Mrs. Turheis and her family, Mrs. Turheis says, I know my risk for infection is really high because of my poor immune status, but I feel so out of touch with reality now. And when I get home, how will I respond to my Sunday school students who are used to greeting me with a big hug? I want to be safe, but I know that I need these hugs too!

After the case presentation, the students will be able to enhance their knowledge, attitude and competence in the care of patients with Leukemia.

 Specifically,

the students will be able to: Define Leukemia and its treatment. Identify signs and symptoms, causes and risk factors of Leukemia. Integrate the 11 Nursing Core Competencies in the care of patients with Leukemia. Formulate and apply nursing care plan utilizing the nursing process for patients with Leukemia. Outline the promotive, preventive, curative management of patients with Leukemia.

 What

is leukemia?

Leukemia is cancer of the blood cells. It starts in the bone marrow, the soft tissue inside most bones. Over time, leukemia cells can crowd out the normal blood cells. This can lead to serious problems such as anemia, bleeding, and infections. Leukemia cells can also spread to the lymph nodes or other organs and cause swelling or pain.

 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.

It may be acute or chronic. Acute leukemia gets worse very fast and may make you feel sick right away. Signs and symptoms may have been present for less than three months, or even as little as a few days. Chronic leukemia gets worse slowly and produces cells that are more functional than acute leukemia, signs and symptoms may arise over a very long period of time, or not at all.

Leukemias are also subdivided into the type of affected blood cell. It may be lymphocytic or myelogenous.
If the cancerous transformation occurs in the type of marrow that makes lymphocytes, the disease is called lymphocytic leukemia. A lymphocyte is a kind of white blood cell inside your vertebrae immune system. If the cancerous change occurs in the type of marrow cells that go on to produce red blood cells, other types of white cells, and platelets, the disease is called myelogenous leukemia.

 The

four main types of leukemia are: Acute lymphoblastic leukemia, or ALL Acute myelogenous leukemia, or AML

Acute promyelocytic leukemia (a subtype of AML)

Chronic lymphocytic leukemia, or CLL. Chronic myelogenous leukemia, or CML

Adults:

AML and CLL Children: ALL, AML and CML

Leukemia statistics are presented here. In 2010, 8,257 people in the UK were diagnosed with leukemia.
In

2010 there were 4,504 deaths from leukemia in the UK. 2005-2009, 44.3% of adult leukemia patients (44.0% of men and 44.4% of women) in England survived their cancer for five years or more.

In

 There

are an estimated 291,521 people living with, or in remission from, leukemia in the US.

In

2013, 48,610 people are expected to be diagnosed with leukemia.

2013, 23,720 people are expected to die from leukemia. 31 percent more males are living with leukemia than females. More males than females are diagnosed with leukemia and die of leukemia.

In

Approximately

The following are either known causes, or strongly suspected causes or risk factors:

Artificial ionizing radiation Viruses - HTLV-1 (human T-lymphotropic virus) and HIV (human immunodeficiency virus) Benzene and some petrochemicals Alkylating chemotherapy agents used in previous cancers Maternal fetal transmission (rare)

Hair dyes
Genetic predisposition Down syndrome Electromagnetic energy Smoking.

*But most people who have these risk factors don't get leukemia. And most people who get leukemia do not have any known risk factors.

 Common

signs and symptoms:

Fever

and night sweats Headaches Bruising or bleeding easily Bone or joint pain A swollen or painful belly from an enlarged spleen Swollen lymph nodes in the armpit, neck, or groin Frequent infections

 Anemia

- this may lead to difficult or labored respiration (dyspnea) and pallor (skin has a pale color caused by illness). very tired or weak Discomfort

Feeling

Abdominal Losing

weight and not feeling hungry

 For

acute leukemia: Induction therapy with chemotherapy is a milestone in cancer treatment. It applies chemicals to kill tumor cell, suppress growth and proliferation of tumor cells and improve differentiation of tumor cells. Chemotherapy is currently still considered as main therapy for cancer.

Chemotherapy

 Bone

marrow transplantation is a procedure to replace damaged or destroyed bone marrow with healthy bone marrow stem cells.

Gather

the patients biological data and the description of the presenting disease. Obtain a thorough health history to aid in diagnosis and treatment. Ask the patient about exposure to risk factors

 Ask

about the frequency and severity of infections. the clients condition including most recent report of blood counts to the patient the primary usage of chemotherapy which is to treat systemic disease rather than lesions that are localized and amenable to surgery or radiation.

Assess

Explain

Explain

the importance of procedure before carrying it out in order to increase understanding of disease and compliance with treatment. psychosocial needs of the patient.

Support

 Provide

comfortable environment by maintaining the room clean and free from noise. the patient that neutropenic precautions need to be taken. should not be any fresh flowers or plants in the room or near the vicinity of the patient.

Teach

There

 Avoid

further complications by securing protective attire when entering the patients room.

Ensures

the functioning of resources. Refer malfunctioning equipment to appropriate unit.

Educational

resources should be available in each health center (e.g. video, flipchart, booklets) and should be used whenever possible.

Explain

the course of the disease to the client. the patient and family members how to recognize signs and symptoms (fever, chills, cough, sore throat).

Teach

Teach

the patient the signs and symptoms of infection to watch for and report temperature of over 37.8 oC, chills, redness or swelling anywhere on the skin, sore throat, or cough.

Explain

diagnostic procedures to the patient.

expected adverse effects of chemotherapy, especially bone marrow suppression (bleeding, infection).

Explain

 Instruct

the patient to watch for signs of thrombocytopenia and to apply ice pressure immediately to the external bleeding site.
the client to obtain adequate rest to minimize fatigue from anemia. minimize the toxic effects of chemotherapy, encourage the patient to eat foods high in calories and protein.

Urge

To

 Secure

informed consent invasive procedure or as recommended by institutional protocol.

every medication and procedure that is done to the patient. nurse should know the scope of Nursing Practice defined in R.A 9173: the liability and responsibility of a nurse to her profession in the practice of medical work.

Record

The

R.A.

9502 -Cheaper Medicine

Law.

R.A.

8423 -Traditional and Alternative Medicine Act (TAMA of 1997 )

Ensure

patients privacy and confidentiality regarding her condition.

speak negatively out patients condition or prognosis especially in the presence of the patients family. on unethical and immoral incidence to proper authorities. the spiritual belief and practices of patient regarding treatment.

Dont

Report

Respect

Consider

the individuality and totality of patient when administering care. beneficence. the right of the client to

Practice Respect

choose.

 Provide

education about leukemia and chemotherapy for patient and family members. expert clinical knowledge and skills and provide a resource service. a helpdesk for health care providers.

Disseminate

Maintain Monitor

patients health status through or by home visits and telephone calls.

Education

for Homecare Patients With Leukemia Following a Cycle of Chemotherapy (Lih-Hwang, 2012). at Home: Keeping Patients in Their Natural Habitat (Crisp, 2012).

Chemotherapy

 Assess

own performance against standard of practice. knowledge and skills. good manners and right conduct

Update

Demonstrate

at all times.
Sets

attainable objectives.

 Educational

and management support resources available for staff include: American Society of Clinical Oncology (ASCO), and Philippine Cancer Society (PCS).

 Maintain

accurate and updated documentation

client assessments, interventions and the impact of interventions on client outcomes according to agency policies. confidentiality. Act as an advocate to protect and promote clients rights to confidentiality and access to information.

Document

Maintain

Update

medication sheet

 Safeguard

the security of printed or electronically displayed or stored information. the care plan clear, current and useful. Document date and time of each recording with signature that each entry clearly identifies the

Keep

Ensure

nurse.

 Establishes

rapport with patients, significant others and members of the health team.
to needs of individuals, family, group and community. in terms that the patient and folks can understand.

Respond

Speak

 Initiate

a nurse-patient relationship.

Encourage

the client to ask questions and actively participate in decision-making.

appropriate information technology to facilitate communication.

Uses

Effective Communication Assess what the patient already knows. Assess what the patient wants to know. Allow extra time. Avoid distractions. Sit face to face. Maintain eye contact.

Listen. Speak slowly, clearly and loudly. Use short, simple words and sentences. Simplify and write down your instructions. Frequently summarize the most important points. Give patient an opportunity to ask questions and express themselves. Be empathetic.

Establish collaborative relationship with colleagues and other members of the health team. Recommends appropriate intervention to improve patient care.

Maintains good interpersonal relationships with patients, colleagues and other members of the health team. Ensure the quality of care.
Support visiting services or specialists.

ASSESSING SUBJECTIVE I know my risk for infection is really high because of y poor immune status, but I feel so out of touch with reality now and when I get home, how will I respond to my Sunday school students who are used to greeting me with a big hug. I want to be safe, but I know I need this hugs too.

DIAGNOSING Ineffective Coping Mechanism related to inadequate coping methods as evidenced by: Verbalization of inability to meet role expectation and inability to make decisions.

OUTCOME CRITERIA LONG-TERM After 1 month of nursing intervention, the patient will be able to demonstrate positive coping strategies, as evidenced by expression of feelings, fears, and hopes initiate realistic goal setting for future.

PLANNING -Establish therapeutic nurse client relationship.

-Determine patients degree/ level of coping.

-Determine support systems/ resources available. -Provide for meeting psychological needs. -Assist patient to deal with current situations.

IMPLEMENTING -Establish a working relationship with patient through continuity of care. -Assess the patients knowledge of disease and treatment plan. -Assess for coping mechanisms used in previous illnesses and hospitalization experiences. -Evaluate resources needed by the patient.

RATIONALE -An ongoing relationship establishes trust, reduces the feeling of isolation, and may facilitate coping. -Because leukemia is cancer, patients may expect to die. Realistic but positive information may be indicated. -Successful coping is influenced by precious success. -Resources may include significant others, health care providers such as home health nurses, community resources, spiritual counseling, and the like.

IMPLEMENTING

RATIONALE

-Assess financial resources -The financial aspects of acute required for expensive long-term care and long-term follow-up can therapy. be overwhelming, especially when the patient is dealing with a new diagnosis. -Establish open lines of -The nurse may be first source of communication; define your role support for the patient and as patient informant and family. The unpredictable nature advocate. of leukemia adds to the stress of the patients daily activities. -Provide opportunities for the patient and significant others to openly express feelings, fears, and concerns. Provide reassurance and hope. Verbalization of actual and perceived threats can help reduce anxiety.

IMPLEMENTING

RATIONALE

-Encourage the patient to seek information that will improve coping skills. -Introduce new information about disease treatment as available.

-Time provides opportunity to assess patient safety and support patient self-esteem. -At this time there is no cure for leukemia . however remission is possible and long-term survival is feasible. -Assist in dealing with change in -Making the patient aware of this concept of body image as complications of therapy will appropriate hasten the patients cooperativity. -Administer tranquilizer, sedative -To facilitate ability to cope. as needed -Assist patient in use of This helps reduce patients diversion and recreation. anxiety and promote relaxation. -Allow client to be dependent in the beginning, with gradual resumption of independence in self-care, and other activities. -It helps develop adaptive coping and problem-solving skills of the patient.

IMPLEMENTING -encourage and support patient in evaluating lifestyle. Identify previous occupation and leisure activities. -Refer to a social worker for financial assistance, as indicated.

RATIONALE -the patients self-worth is enhanced and may help increase confidence for behavior in actual situation. -The social worker can assist the patient and family with decisions about finances, living arrangements, wills, advance directives, and the power of attorney. -Participation in support groups may allow the individual to realize that others have the same problem, and they may use this as an aid for coping.

-Encourage participation in selfhelp groups as available.

EVALUATION MET. LONG-TERM After 1 month of nursing intervention, the patient was able demonstrate positive coping strategies, as evidenced by expression of feelings, fears, and hopes initiate realistic goal setting for future.

DISCHARGE PLANNING Medication Instruct the patient and family to comply with the medications prescribed(tranquilizer, sedative) Avoid medicines called NSAIDS: These are medicines used to reduce pain. They thin blood and make it easier to bleed. Environment -Provide quiet, nonstimulating environment. Advise to avoid exposurefrom crowds and from people with colds and other contagious diseases Treatment -Dental care treatment: Instruct patient to always keep mouth clean and healthy. (Leukemia and chemotherapy can make the mouth sensitive, easily infected, and likely to bleed)

DISCHARGE PLANNING Health Teaching -teach client to Get plenty of rest: Rest as much as you need to. Match your activity to the amount of energy you have. Instruct to use diversional activities as methods to cope with stress. Out- patient - Stress importance of follow-up care. Checkups may include a careful physical exam, blood tests, x-rays, bone marrow aspiration Diet - Instruct to eat small, frequent meals and nutrient-dense foods, low-fat, bland diet of cold foods. Instruct to take iron and folic acid supplements to boost red blood cell count. a well-balanced, protein-rich diet to help your blood counts return to a safe level and increase your fiber intake and stay hydrated to relieve constipation.

Support System -Evaluate resources and support systems available to the patient. Refer to outside resources and/or professional therapy as indicated.

Provide Reverse

nutritious diet Isolation precautions

Neutropenic

Complete

blood counts and bone marrow examinations. high doses of radiation, exposure to the chemical benzene and smoking.
blood tranfusion.

Avoid

Limit

 The

patient should also consume a high quantity of fluids such as water and juice to avoid dehydration. Clothing can help prevent germs and microorganisms from coming into contact with the patient. The patient should not under any circumstances be visited by anyone with a transmittable disease

 Chemotherapy

is the major form of treatment for leukemia.

Drug therapy is divided into three phases: induction, consolidation and maintenance phase.

Induction therapy is intense and consists of combination chemotherapy started at time of diagnosis.

 Consolidation

therapies often consist of another course of either the same drugs used for induction at a different dosage or a different combination of chemotherapy drugs.

Maintenance

therapy may be prescribed for months to years after successful induction and consolidation therapies. therapy

Radiation
Stem

cell therapy or Bone marrow therapy

Auriculotherapy:

This noninvasive technique, which involves an electrical stimulation to the external ear. Therapy
Care

Massage

Supportive