Acute Lymphoblastic Leukemia (ALL) SKINNY Reasoning

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Acute Lymphoblastic Leukemia (ALL) SKINNY Reasoning 1 Acute Lymphoblastic Leukemia (ALL) SKINNY Reasoning April Peters, 10 years old Primary Concept Cellular Regulation Interrelated Concepts... (In order of emphasis)  Infection  Perfusion  Clinical Judgment  Patient Education NCLEX Client Need Categories Percentage of Items from EachCategory /Subcategory Covered in Case Study Safe and Effective Care Environment Management of Care 17-23% Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% Psychosocial Integrity 6-12% Basic Care and Comfort 6-12% Pharmacological and Parenteral Therapies 12-18% Reduction of Risk Potential 9-15% Physiological Ada tation 11-17%23 Part 1: Recognizing RELEVANT Clinical Data History of Present Problem: April Peters is a 10-year-old female with acute lymphoblastic leukemia (ALL) who presents to the emergency department with a temperature of 38.4 degrees C. (101.2 F.) and a complaint of a sore throat. She has been receiving chemotherapy since her diagnosis three months ago. April's mother reports that her fever has been unresponsive to acetaminophen and she is two days out from her most recent chemotherapy treatment. No reports of nausea, vomiting, or diarrhea noted. A CBC is drawn immediately from April's central venous access device (CVAD) and April is admitted directly to the pediatric oncology unit where you are the nurse responsible for her care. She weighs 57 lbs. (25.9 kg), is 51.5 inches (128.8 cm.) and has NKDA. Personal/Social History: April lives at home with her mother Cindy, her father Tom, and her 6-year-old sister Maggie. Tom works fulltime as an engineer while Cindy stays home with the children because of April's diagnosis and resulting hospitalizations and treatment. April has missed quite a few days of school. Although her school system has provided April with a tutor to keep up with her studies, April does not return telephone calls from her friends and refuses their visits. Past Medical History (PMH): o Cindy's pregnancy was uneventful and April was born via an uncomplicated vaginal delivery at 40 weeks and weighed 7 lbs., loz. (3.2 kg.) o Tonsillectomy at 3 years old under general anesthesia. o ALL diagnosis 3 month ago following a short history of headaches and pallor. April's WBC count at diagnosis was 469,000 FYI: Hyperleukocytosis is defined as a peripheral white blood cell count greater than 100,000/mm3 and is a pediatric oncologic emergency. These white blood cells are immature blast cells not normal cells. Hyperleukocytosis can progress to capillary obstruction, microinfarction, and organ dysfunction, which can lead to respiratory distress and cyanosis. Children may also experience changes in neurologic function, including an altered level of consciousness, visual disturbances, confusion, and ataxia. What data from the histories is RELEVANT and has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: 10-year-old female with acute lymphoblastic leukemia (ALL) She has been receiving chemotherapy since her diagnosis three months ago. She is two days out from her most recent chemotherapy treatment. It is important to know that the patient is 10 years old to adapt the plan of care to her stage of development. Knowing her cancer diagnosis of ALL is key to understanding that she is presenting as an emergent case and what nursing interventions are critical for a patient with ALL. Knowing she was only diagnosed 3 months ago is very important to note as she has not dealt with the disease very long, is currently undergoing chemotherapy and had her last treatment two days ago. This information can provide insight to what is causing her symptoms and what diagnostic testing should be done. Also, it tells us she is actively fighting the cancer and is not in remission, thus making her immunocompromised and susceptible to infections. ALL is characterized by cancerous cells in the bone marrow producing excessive amounts of immature white blood cells that can lead to damage in the circulatory system and in the organs of the body if levels are too high. Chemotherapy is used because it destroys the cancerous tissue. Unfortunately, it also affects healthy tissues/cells and reduces the white blood cell count, cancerous and healthy, until the immune system is no longer able to function efficiently to be able to fight off foreign bacteria and invading viruses. Temperature of 38.4 degrees C. (101.2 F.) and a complaint of a sore A temperature over 100.4 in pediatric patients with cancer is considered an emergency! Fever and sore throat are signs of4 throat. April's mother reports that her fever has been unresponsive to acetaminophen and no reports of nausea, vomiting, or diarrhea noted. A CBC is drawn immediately from April's central venous access device (CVAD) and April is admitted directly to the pediatric oncology unit infection, reactions/side effects to chemotherapy. Chemotherapy often causes pain and irritation of various tissues, it causes patients to feel fatigue and malaise. An unresponsive fever despite interventions requires immediate intervention Knowing if the patient is experiencing nausea etc. is important to help the healthcare team distinguish the possible cause of the patient’s symptoms. Since ALL occurs with too many immature WBCs and lifethreatening complications can occur, it is important to draw labs immediately and admit the patient. CBC, liver panels and other labs will give insight to her immune status, if she requires neutropenic precautions, if any of her organs are being affected by her chemotherapy and for signs of possible sepsis or cancer complications. Her CVAD will be used to reduce any new portals of infection and for efficiency as patients veins are difficult to start IVs with as their veins RELEVANT Data from Social History Clinical Significance: April has missed quite a few days of school. Although her school system has provided April with a tutor to keep up with her studies, April does not return telephone calls from her friends and refuses their visits 57 lbs. (25.9 kg), is 51.5 inches (128.8 cm.) and has NKDA. Difficulty keeping up with school and not wanting to speak and see friends could indicate that April is struggling to adjust to her diagnosis and the symptoms that come along with ALL. Also, the side effects of chemo drugs likely affect her self esteem and she may feel depressed. Being around other children is very important for a child’s development socially and developmentally as their interaction with others allows them to learn more about interactions and how the world works. Without it, it places her at risk for delayed social development that will leave her possibly struggling with identifying and communicating with others now and in the future. Knowing her height and weight is important to calculate safe dosages of her medications as well as knowing if she has any allergies. Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 100.8 F/38.2 C (oral) Provoking/Palliative : "My throat hurts" P: 112 (reg) Quality: "Bad" R: 24 (reg) Region/Radiation: Throat BP: 102/66 Severity: "I don't know." 02 sat: 96% on room air Timing: Ongoing5 What VS data are RELEVANT that must be recognized as clinical significance by the nurse? RELEVANT VS Data: Clinical Significance: T: 100.8 F/38.2 C (oral) P: 112 (reg) R: 24 (reg) "My throat hurts" “Bad” Throat “I don’t know” ongoing Fever over 100.4 is dangerous, it is also a sign of infection/immune response. Fever is also a symptom of ALL and further diagnostic testing would be required to determine if the fever is occurring due to an infection or as a result of the cancer. Pulse is elevated, could accompany fever. The patient is likely afraid, they feel ill and they have just been diagnosed with cancer and began undergoing chemotherapy. Chemotherapy suppresses all functions of the body and the production of WBCs and RBCs which affects both the immune system and the circulatory system. Anemia is a condition with less RBCs meaning that the body has less healthy hemoglobin to carry adequate oxygen to the body which would lead to an increased pulse and respiratory rate to compensate for the oxygen demands. Elevated RR corresponds with the tachycardia. Could be related to the fever or the patient’s possible anemia that is secondary to her cancer treatment suppressing her RBC production. Less oxygen carrying capacity would cause the body to compensate by moving the blood through the circulatory system faster to pick up oxygen and move it throughout the body fast enough to meet the demand. The source of pain in the throat could indicate an infection, specifically a strep throat infection that is common among children. It is caused by the Streptococcus genus and is characterized by white exudate on the tonsils, mouth and throat. It is very painful and lymph nodes are commonly sore and swollen. It could have been an infection that could possibly have developed into a systemic bacterial infection. Possibly, she could have developed mucositis which is common with chemotherapy and occurs when tissue becomes inflamed and irritated and it may have become a portal of entry for the infection to take root and become strep throat, before entering the bloodstream. Likely is not suffering from decreased oxygen levels or any oxygen issues at this point in time. However, at 10 years old with no other respiratory issues she should have a O2 saturation near 100%. Having oxygenation at the lower end could be related to anemia secondary to her chemotherapy treatment.6 O2 96% RA All of these VS data indicates an infection supported by pain in the throat. These are all significant findings for a patient with leukemia because classic signs of infection may be absent due to bone marrow suppression and infection is a major concern for a child receiving treatment for cancer.7 Current Assessment: GENERAL APPEARANCE: Resting in bed with eyes closed, pale in appearance. RESP: Breath sounds clear with equal aeration bilaterally, unlabored respiratory effort CARDIAC: Skin is pale, cool to touch. Cap. Refill 3-4 seconds in both hands. No edema noted, heart sounds regular with no abnormal beats, radial and pedal pulses present and strong. NEURO: Patient appears lethargic, drowsy, oriented x4. GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants. Last BM yesterday evening GU: Voiding without difficulty SKIN Skin integrity intact. Central venous access device (CVAD) in place, dressing intact What assessment data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: Resting in bed with eyes closed, pale in appearance. Resp is within normal limits Skin is pale, cool to touch. Cap. refill 3-4 seconds in both hands. The patient is presenting as very ill, likely feels malaise and has developed a serious condition (infection most likely). Also, with severe anemia patients feel lethargic and become pale due to the lack of oxygen being circulated through the body and the elevated pulse and respiratory rate use more energy to help compensate for the lack of oxygen carrying capacity. The patient is not experiencing anything major affecting her oxygenation ability in her respiratory system, mechanically. However, if her oxygen carrying capacity is low her respiratory system will begin to compensate if the underlying cause is not treated (anemia). The paleness is likely due to two factors. One is anemia which causes a reduction of the red appearance in the skin due to low numbers of RBC in the blood. Second is that paleness is an indicator of poor circulation. The coolness of the patient’s skin indicates poor circulation also and possibly chills as the patient has a fever. The extended capillary refill is very alarming and may indicate a serious illness (sepsis etc) and/or dehydration. Dehydration would occur quickly in a child who is immunocompromised and fighting a severe infection. Signifies the severity of the patient’s condition. A 10 year old should be up and alert. She has undergone draining chemotherapy treatments and has now developed a serious infection that her body is too weak to fight off, wreaking havoc on any energy stores and immune system. Anemia caused by her chemotherapy could also contribute to feeling lethargic as her body has to compensate (PR/RR) to meet the body’s oxygen requirements. A patient who is immunocompromised and ill should immediately be placed on neutropenic precautions. CVAD allows for convenient access for patients undergoing chemotherapy. However, they could also be portals of infection and the patient should only have I.V. access through this port to limit instances that may introduce8 lethargic, drowsy, Central venous access device (CVAD) in place, dressing intact GU: urinating without difficulty bacteria. Especially when infection is suspected. It is important to assess the CVAD portal site routinely with blood cultures because it can get infected if not cared for properly. A pt with ALL with any type of portal access is especially at high risk for infection and an immunocompromised patient will poorly tolerate even a minor infection. A full GU assessment should be conducted, evaluating when her last void was, what the color, clarity and diagnostic levels did it have? It could indicate if she could possibly have a UTI as the source of her infection? Her age group is predisposed to UTIs as they may have poor elimination habits and she is more susceptible to infections as she is immunocompromised and is a female. Diagnostic Results: BMP Na K Gluc. Creat. Current 130 3.5 70 1.4 Most Recent 129 3.3 82 1.1 CBC WBC HGB PLTs % Neuts Bands Current 0.2 7.4 54 1 0 Most Recent 0.36 8.2 61 0 0 Liver panel Albumin Total Bili Alk. Phos. ALT AST Current 3.5 1.0 75 42 49 Most Recent 3.9 0.9 79 20 21 MISC Lactate Ionized Ca Mg Amylase Lipase Current 1.8 I .05 1.9 29 31 Recent 1.7 1.11 2.0 31 399 What data must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) Relevant Data: Clinical Significance TREND: Improve/Worsenin g /Stable: Cr 1.4 Normal: 0.5 – 1.0 mg/dL for 10 years old Elevated levels are likely due to the pt’s recent chemotherapy treatment as it is harmful to all tissues and would affect the kidneys ability to function normally. Also, dehydration leads to higher levels. Worsening WBC 0.2 Normal: 5,000-10,000 /mm^3 Critically low is below 2,000. This is a significant drop from 3 months ago. Although a lower value is expected in her condition due to chemotherapy treatment and ALL, this is extremely low and makes the patient immunocompromised as her WBC level is too low for her immune system to function properly against any illnesses/infections. Worsening. AST 49 Normal AST value is 10-15 unit/L. Elevation in AST can be due to the recent chemotherapy treatment or can be an indicator for liver damage as it is released when the cells are damaged by the chemotherapy. Worsening ALT 42 Normal: 4-36 units/L. Elevated. Chemotherapy can induce abnormalities of the liver function as it damages healthy cells leading to the release of alt. Her bili levels are still within the normal range, although on the higher end. This may be an indicator of liver dysfunction related to her chemotherapy treatment. Worsening PLT 54 Normal: 150,000-400,000/mm^3.Extremely low, likely due to chemo treatment. Cytotoxic drugs often affect the bone marrow and platelets are not produced at adequate levels. This is important because platelet activity is essential to blood clotting and puts the patient at risk for prolonged bleeding. Worsening Albumin 3.5 Normal: 4-5.9 g/dL. Slightly low. This indicates a protein abnormality that is typically seen in hematologic malignancy. This may also be an indicator of inadequate production by the liver, especially combined with elevated liver enzymes. This would indicate a delay in RBC production that is related to anemia, which would account for the patient’s symptoms of increased PR/RR/paleness/Lethargy. Worsening HGB 7.4 Normal hemoglobin count for a 10 y/o is 10-15.5 g/dL. critically low is below 7 and she is near requiring a blood transfusion. Decreased levels of hemoglobin is expected in patients with ALL but a decreasing trend is an indicator of a worsening condition. Low hemoglobin Worsening10 count can affect her respiratory functions as it attempts to compensate for low oxygen capacity. This correlates to anemia and the suppressed production of RBCs. Neutrophils 1% Normal: 55-70%, without adequate white blood cells the body is ill equipped to fight off infections. Neutrophils are especially important for acute bacterial infections. healthy wbcs are made with functioning bone marrow, if this process is suppressed as it is with chemotherapy then the body will not have a functioning immune system. worsening11 Part II Put it All Together to THINK Like a Nurse! 1. After interpreting relevant clinical data, what is the primary problem? (Management of Care/Physiological Adaptation) Problem: Pathophysiology in OWN Words: Infection/neutr openia/anemia related to chemotherapy Chemotherapy is used to treat cancer. As it destroys cancerous cells it also affects healthy cells which leads to suppression of various functions of the body. WBC and RBC production is suppressed, leading to neutropenia and anemia where there are not enough mature, healthy WBCs to fight off infections and low RBC levels that impact the body’s ability to meet its oxygen demands. Neutropenia is very common with chemotherapy treatment and strict precautions of washing hands, wearing face masks and limiting contact with others to avoid contracting any illnesses as her low WBC count leaves patients very vulnerable as their immune system is not effective against any sort of infection. While the body is trying to fight off the infection despite not having a functioning immune system, the body uses up more oxygen and energy to do so. This stresses the body’s oxygen carrying capacity is suppressed with less RBCs and hemoglobin production to circulate enough oxygen to meet demands. Strong antibiotic treatment and strict monitoring of her vitals, I & Os, CBC and lab data and monitoring her infection status to help her fight off the infection. Until the infection is treated the body will continue to employ compensatory measures. Collaborative Care: Medical Management 2. State the rationale and expected outcomes or the medical plan of care. (Pharm. and Parenteral Therapies) Medical Management: Rationale: Expected Outcome: Admit to Pediatric Oncology unit with strict neutropenic precautions. The patient is presenting with a pediatric emergency, she is immunocompromised and requires strict neutropenic precautions to help prevent the patient from catching any infections or viruses. The healthcare team and any visitors should all wear simple face masks when in the same room as the patient to prevent her from contracting anything from others. Everyone should be frequently washing their hands and being careful with cleaning whatever is brought into the room that the patient will interact with. Visitors should be limited to family to reduce her interactions with others who may be sick or carry an illness to the patient. Patient will be protected from potential sources of pathogens or infection and will not develop nosocomial infections.12 Daily weight Documenting daily weight is crucial for monitoring fluid status and health of the child in general. This is also important in determining the child’s medication doses which will allow for safe medication administration. The patient should not lose or gain more than 3-5% (0.77-1.295kg) of her body weight each day and once the patient is hydrated it will be expected that her weight will increase due to the increase in fluid volume. Her pulses, cap refill etc. should be within the normal range. Significant changes would indicate rapid changes in her fluid status. each kg lost is 1000ml and she should not lose more than her intake of 1,548ml/day. Strict I & 0 Monitoring what the patient intakes and eliminates will provide accurate data about the patient’s health status and fluid status to identify early signs of changes in her condition. Dehydration, nutrition, kidney function etc. The patient will meet her daily fluid intake of 1,548 ml/day parenterally or by mouth. She will eliminate at least 25.9ml/hr to adequately eliminate waste products the body produces. Her fluid status will also be monitored by assessing her skin turgor (immediate), capillary refill (2-3sec), pulses (2+), blood pressure and for them to be within normal limits for a 10 year old child. 0.9% NS bolus @ 20mL/kg over 60 minutes then D5.45 NaC1 with 20 mEq/L KCL at 2 mL/kg/hr Proper hydration treatment enhances the immune system, promotes healing and helps avoid constipation as it could lead to further complications. It also aids her kidneys, liver and other organs to remain properly perfused as the chemotherapy is likely affecting their ability to function and dehydration will lead to more decreases in their functionality, as shown in her laboratory values. It is also very important to hydrate the patient in phases as children are especially susceptible to becoming overhydrated and this could lead to damage in her brain if she quickly becomes hydrated as it may lead to fluid overload. Fluid status and vitals will be evaluated every 15 to 30 minutes while the patient is undergoing the hydration treatment. pulses, blood pressure, urine output, capillary refill, skin turgor will all show signs of improvement towards their normal ranges (see above). Her kidney function should also shift towards the normal range as she maintains adequate hydration and perfusion to avoid stressing out the organs. Daily blood cultures from all CVAD lumens. Blood cultures must be taken from the existing CVAD lumens to limit new breaks in skin that could provide an entry for pathogenic or potentially lethal organisms. Use of central venous lines (tunneled catheter or implanted port) can effectively reduce need for frequent invasive procedures and risk of infection. Myelosuppression may be cumulative in nature, especially when multiple drug therapy (including steroids) is prescribed. Limiting invasive procedures such as venipuncture as much as possible. Allows It will be the diagnostic means of identifying what bacteria is causing her infection. Her blood cultures will correspond to the rapid strep test if that is the source of infection. With her treatment with ceftriaxone and vancomycin the blood cultures will begin to show a decrease in the presence of the infection microorganism. If her fever is related to the infection, her fever will reduce as well as the cultures also show a reduction. Her antibiotic treatment will be altered with the reduction of her infection and it will be the indicator that antibiotics13 healthcare team to identify any bacteremia present in the patient’s system and to identify what organisms are invading her circulatory system. This would allow the doctor to prescribe antibiotics/medication that will target any identified microorganism. Blood cultures are very useful as her fever and wbc/cmp are also influenced by ALL and her chemotherapy. If it is a different bacterium, it would be likely that the CVAD itself may have been the portal of entry can be discontinued. Vital signs every 2 hours and as needed VS every 2 hours will allow for close monitoring of the patient for any changes. This will indicate a worsening or improving status. Monitoring her vitals every 15 to 30 minutes while initiating hydration therapy is also important as she should be closely monitored for changes in her hydration status, which would show in her vitals as well. The patient’s vital signs will be monitored for any signs of her condition worsening or improving in response to treatment. normal PR: 70-110 normal RR:19 Normal O2: 95-100% pain: within acceptable range as described by patient. normal temperature: 36.7C Normal BP: around 97 -112 systolic and 57-73 diastolic Acetaminophen (160 mg/5 ml) 5ml PO every 4 hours for temp > 100.4 F. (38.0 C.) Acetaminophen is an antipyretic and will help reduce the patient’s fever. Reducing the fever will prevent dehydration and facilitate proper system function. The patient will have a temperature less than 100.4 F within 4 hours or a reduction in her fever. Acetaminophen will be continued until her temperature is around 36.7C. Ceftriaxone 75mg/kg IV every 24 hours. Cetriaxone is a broad-spectrum antibiotic that can be administered prior to a throat culture as an initial anti-infective agent. Ceftriaxone will help fight the patient's serious infection and work against the invading bacteria by inhibiting its replication. It is commonly used with vancomycin for systemic infections. After routine treatment, the patient’s health status should improve, fever should be reduced below 100.4F, further cultures should show reduction or elimination of an infection, her WBC count should increase as well near her recent WBC level. Rapid strep/throat culture A throat culture will help identify specific organisms for appropriate therapy. This can also verify the presence of the infection. Sensitivity testing will allow strategic care planning to incorporate antibiotics that are effective against the identified organism to fight off the infection. [Show More]

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