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Case Study Paper
Bianca Iafrate
University of New Hampshire
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Epidemiology/Pathophysiology
Acute myeloid leukemia (AML) results from a defect in the hematopoietic stem
cell that differentiates into all myeloid cells: monocytes, granulocytes (neutrophils,
basophils, eosinophil’s), erythrocytes, and platelets. Specifically, there is an excess of
myeloblasts, which would be found through a WBC with a differential. Exceeding 30%
of leukemic blasts in a bone marrow aspirate is required for a definitive diagnosis of
AML (Lowenberg, 1999). The blast cells have taken over and are producing an excess of
immature white blood cells, which prevent the development of healthy WBCs, RBCs,
and platelets. There becomes such excess that they spill out into the blood stream, which
is how they are found through blood cultures.
There is not a specific age group that is mostly affected by this disease, although
it is not as common in those younger than age 55. The chances of developing the disease
do increase with age and peaks at about 67 years old (National Cancer Institute, 2011).
The prognosis tends to become worse with age, in that stem cells of the elderly are slower
and slowly produce the white blood cells necessary to fight off infection. This leads to
their immune system weakening and further healthy complications follow secondary to
the disease. In the United States, the yearly incidence of AML is approximately 2.4 per
100,000 and as mentioned, increases progressively with age. The survival rate among
patients who are less than 65 years old is only 40% (Lowenberg, 1999). Symptoms of
AML usually occur over a period of weeks and happen suddenly. The causes of the
symptoms are due to the lack of normal blood cells being produced. Fever and infection
result from a low neutrophil count; weakness and fatigue, dyspnea on exertion, and pallor
from anemia; petechiae, ecchymosis, and bleeding tendencies from thrombocytopenia
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(Hinkle & Cheever, 2014). Other symptoms include splenomegaly, hepatomegaly,
lymphadenopathy (enlarged organs), hyperplasia of the gums, loss of appetite, night
sweats, back and joint pain/tenderness, and bone pain from expansion of marrow
(National Cancer Institute, 2012a).
Case Study Prompts
C.O. is a 43-year-old woman who noted a nonpruritic nodular rash on her neck
and chest approximately 6 weeks ago. The rash became generalized, spreading to her
head, abdomen, and arms and was accompanied by polyarticular joint pain and back pain.
About 2 weeks ago, she experienced three episodes of epistaxis in 1 day. Over the past
week, her gums became swollen and tender and she was severely fatigued. Because of the
progression of symptoms, she sought medical attention. Lab work was performed, and
C.O was directly admitted to the hematology/oncology unit under the care of a
hematologist for diagnostic evaluation. Her chest x-ray examination showed normal lung
expansion and heart size, without lymphadenopathy. Skin biopsy showed cutaneous
leukemic infiltrates, and bone marrow biopsy showed moderately hypercellular marrow
collections of monoblasts. Her lumbar puncture specimen was free of blast cells. The
final diagnosis was acute myeloblastic leukemia.
C.O. is to begin remission induction therapy with cytrabine (Ara-C)
100mg/m2/day as a continuous infusion for 7 days and idarubicin (Idamycin)
12mg/m2/day intravenous (IV) push for 3 days. She is scheduled in angiography for
placement of a triple-lumen subclavian Hickman catheter before beginning her therapy.
She has multiple symptoms that correlate with the diagnosis of AML including:
rash, spontaneous bleeding, joint pain, fatigue, and tender gums. A skin biopsy and
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laboratory work is the best way to confirm this diagnosis. The bone marrow biopsy is
done to examine and diagnose cell type and in this case, to confirm malignancy. Her
complete blood count (CBC) came back showing very elevated white blood cells and
monocytes. Her lymphocytes and neutrophils were decreased, as well as her hemoglobin,
hematocrit, and platelets. The most important finding is that her blast cells came back at
17%. In healthy individuals, blasts are not found in the blood stream and for this patient,
it shows that there is excess causing them to dump from the bone marrow into the blood
stream.
Before beginning her chemotherapy, she had a triple lumen subclavian Hickman
catheter inserted. After C.O. returns to the unit there are different assessments that the
nurse should perform and things to monitor. Potential problems that can occur are
erythema, bleeding, irritation, infection, and displacement (Sommer et al., 2013). An Xray is essential to confirm the placement of the catheter and in the event that it is
suspected that the catheter is displaced. Phlebitis, infiltration, extravasation, and air
embolism should be assessed for. The nurse should monitor for signs of infection
(redness, swelling, drainage, tenderness) as well as monitoring the condition of the
dressing and changing it per facility protocol. The catheter should always regularly be
assessed for good blood return and flushed with 10mL syringes.
After placement of the catheter, she is to receive cytrabine and idarubicine.
Cytarabine is an antimetabolite, which interferes with the biosynthesis of metabolites and
acids necessary for RNA and DNA synthesis, as well as inhibiting DNA replication and
repair (Sommer et al., 2013). Idarubicin is an antitumor antibiotic that interferes with
DNA synthesis by binding DNA and preventing RNA synthesis (Sommer et al., 2013).
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These chemotherapy agents’ works to stop the replication of the leukemia cells and
allows the body to repair and produce healthy blood cells again. There are important
adverse effects to note for each of these medications and nursing interventions that
follow. Cytarabine’s adverse effects include: liver disease, pulmonary edema,
arachnoiditis (indications include nausea, headache, and fever), and it may reduce
digoxin levels. The nurse should monitor liver enzymes, indications of jaundice, breath
sounds, as well as advising the patient to notify the provider of shortness of breath,
nausea, vomiting, headache, or fever. These manifestations may be treated with
Decadron. Digoxin levels and EKG should also be monitored.
extravasations off vesicants, and alopecia. The patient’s WBC, ANC, platelet
count, and Hgb/Hct should be monitored; assess for bruising and bleeding gums, avoid
crowds and contact with infectious individuals, administer antiemetics before beginning
chemotherapy (Zofran), stop chemotherapeutic medications if extravasation occurs.
Advise patients that hair loss will occur 7-10 days after beginning of treatment and will
last for a maximum of 2 months after the last administration.
Five days into her continuous infusion of cytarabine, her vital signs are reported:
110/54mm Hg, 115, 26, 101.6F. At this point, the nurse should perform neuro
assessments; auscultate heart and lungs, and checking her CBC. Tachycardia is a
symptom of anemia so monitoring her labs is important. The nurse should look for other
signs of infection because although she does have a high temperature, she does have an
increased WBC due to her AML so this could just be a contributing factor. A high
temperature could also be the result of arachnoiditis; so close monitoring should be done.
After notifying the intern of these findings, there are new orders written: blood cultures
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now x2 sites, Acetaminophen (Tylenol) suppository 650 mg q4-6h prn,
Imipenem/Cilastatin sodium (Primaxin) 500 mg IVPB q8h, and notify the physician for a
temp greater than 100.0F. As mentioned, blood cultures should be done to watch for a
decrease in Hgb/Hct for anemia, decrease in platelet count for thrombocytopenia,
increase or decrease in WBCs with differential. Acetaminophen will help control C.O.’s
rising fever and if she were to experience headaches. Primaxin will work to treat any
additional infection, and notifying the physician for a high temperature should be done as
well.
Catheter care should be continued per facility protocol and monitoring for adverse
effects mentioned above. Regular vitals signs and assessing for bleeding and/or bruising,
especially when her laboratory results have not been seen. One her last day of continuous
chemotherapy, her laboratory findings were reported. Her WBC decreased dramatically
to 1,200/mm3, as did her Hgb, Hct (6.8g/d, 21.3%), and platelet count (49,000/mm3 to
17,000/mm3 ) from admission. Her lymphocytes have increased and her monocytes have
decreased from admission. Her neutrophil count increased by only 1% (4%-5%), but
luckily her blasts have gone from 17% on admission to 5% and she has no evidence of
bands in her blood. Looking at these lab findings, her calculated ANC is 60. Neutropenia
is diagnosed for an ANC of 1,000 or less, so C.O. has developed neutropenia. Her WBC
count and neutrophil count is abnormally low and her immune system has weakened,
making it even harder for her body to fight off infection. Her decreased Hgb and Hct
indicate anemia and her decreased platelets put her at a high risk for bleeding.
Considering this data, she will most likely receive packed RBC’s and platelets.
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On day 14 after completion of her therapy, a bone marrow biopsy shows C.O. is
in complete remission. This means that there are no signs of cancer in test, physical
exams, and scans. This does not however, mean that you are cured. With continued blood
product support and antibiotic coverage, her marrow recovers and she is discharged from
the hospital. HLA (human lymphocyte antigen) typing has been performed on all
siblings. Her oldest brother is a perfect HLA match and has agreed to donate bone
marrow or stem cells. C.O. is to be readmitted to the bone marrow transplant unit within
the next few weeks. In Williams’ “Comprehensive Review of Hematopoiesis and
Immunology”, he explains that when bone marrow transplants (BMT) was done on
patients in chemotherapy-induced remission, the mortality rate decreased, due to a lower
relapse rate and a decreased rate of transplant-associated mortality. The risk of relapse is
also lower when it is earlier in the course of the disease.
Allogeneic Hematopoietic Stem Cell Transplantation (AlloHSCT) is from a donor
other than the patient, including possibly a related donor such as a family member. C.O.
will have this type of BMT done because her brother is going to donate. During this
process, C.O. receives high doses of chemotherapy and possibly total-body irradiation to
completely eradicate the bone marrow and any malignant cells and help prevent rejection
of the donor stem cells. The collected HSCs are infused IV into the recipients and travel
to sites in the body where they produce bone marrow and go through the process of
engraftment to place themselves (Hinkle, 2014). Engraftment may take 2-4 weeks (or
perhaps longer), and once complete, the new bone marrow becomes functional and
begins to produce healthy RBCs, WBCs, and platelets.
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When undergoing a bone marrow transplant, C.O. will be at high risk for
infection, sepsis, and bleeding, as well as possible side effects from the high dose
chemotherapy (nausea, vomiting, fluid/electrolyte imbalance, etc.). Real complications
can also arise from nephrotoxic chemotherapy agents. As the nurse, it is important to
monitor vitals signs and blood oxygen saturation, assess for adverse effects such as:
fever, chills, shortness of breath, chest pain, nausea, vomiting, hypotension or
hypertension, tachycardia, anxiety, and taste changes. Her CBC should be monitored
because until the body starts to produce healthy blood cells again, anemia, excessive
bleeding, and infection become a higher risk. Skin care and mouth care should also be
interventions.
In any bone marrow transplant, patients are at a risk for graft-versus-host disease.
In this disease, the donor cells view the recipient’s tissues as foreign. The donor
lymphocytes initiate an immune response against the recipient’s tissues (skin, GI tract,
liver) during the beginning of engraftment (Harris, 2010). Clinical manifestations of
acute GVHD: rash progressing to blistering and appearance similar to second-degree
burns, mucosal inflammation of the eyes and the entire GI tract with subsequent diarrhea
that may exceed 2L per day, and biliary stasis with abdominal pain, hepatomegaly, and
elevated liver enzymes progressing to obstructive jaundice. Complications that can occur
during the first 100 days are encephalopathy, hemolytic uremia syndrome, hemolytic
anemia, and thrombotic thrombocytopenia. Clinical manifestations of chronic GVHD:
dry eyes or vision changes, dry mouth, white patches inside the mouth, fatigue, muscle
weakness, chronic pain, joint stiffness, skin rash with raised, discolored areas, as well as
skin tightening, SOB, vaginal dryness, and weight loss.
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Evidence/Research Based Support
A retrospective study of 740 patients treated for grade II-IV aGVHD, 531 patients
were treated with steroid and complete or partial responses were achieved in 44% of
patients with improvement in skin, liver, and gut disease at 43, 35, and 53% (Jamil &
Mineishi, 2015). Table 2 (below) shows the staging and grading of graft-versus-host
disease. Steroid and CI remain the standard for initial treatment of the disease.
In a peer reviewed journal article, a case study was discussed of a 43-year-old
mother of four children diagnosed with AML. Throughout her hospitalization, she
complained of severe pain, numbness and tingling, sweats, depression, and overall
distress. She worried often and was anxious and had trouble sleeping. She received
different medications to help relieve these symptoms. Psychological and emotional care
given by the nurses was a main point in this article. Nurses would make sure to give her
periods of rest in a quiet, dimly lit room. Emotional distress is common in patients with
cancer and has been of interest to healthcare providers for decades (Holland, 1977;
Weisman & Worden, 1976). Emotional distress is an established factor in patients’
decisions to reduce or stop treatment (Nerenz, Leventhal, & Love, 1982).
Psychoeducational interventions can include education and supportive attention, which
are recommended for the reduction of anxiety (Galway et al., 2012). Patients with this
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kind of disease need to be informed about the disease process, their medications, side
effects, etc. to helping them understand and to help them get past certain barriers that are
making them want to stop treatment or fall into depression.
Summary/Conclusion
Williams’ “Comprehensive Review of Hematopoiesis and Immunology” helped
to give me a better understanding of the transplantation process. The advances of BMT
have depended heavily on the availability of blood component support. (Williams, 2004).
It also helped me to review the basics of understanding hematopoiesis and the disease
process. In 2008 a study was done to test the effects of radiotherapy as a way to control
joint pain in patients with AML. This was a peer reviewed journal article that observed an
80-year-old female’s pain before and after radiation therapy. Prior to the therapy, she was
completely bedridden and standard pain management was unhelpful. With low doses of
radiotherapy, she was able to participate in physiotherapy with minimal to no pain under
her death several weeks later (Chakraborty et al., 2008). There are few cases to help
support this evidence, but leukemic cells are relatively radiosensitive, hence the low
prescribed dosage.
The primary objective in treating patients with AML is to induce remission and
thereafter prevent relapse (Lowenberg, 1999). Cytarabine is one of the hallmark
treatments to induce remission, which was what C.O. was being given. Based off the
literature that I found, targeting the malignant cells with therapeutic strategies is essential.
After undergoing a BMT, nurses have to watch closely for beginning signs and symptoms
of graft-versus-host disease. For those who develop chronic GVHD, steroids are the top
treatment. Topical corticosteroids can be used for skin GVHD and an immunosuppressant
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can also be prescribed as the condition worsens. It is critical to recognize and treat
chronic GVHD early, before all other organs become affected.
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References
Albrecht, T., Walton, A. L., & Bryant, A. L. (2015). The Unique Supportive Care Needs
of a Mother With Acute Myeloid Leukemia During Treatment. Clinical Journal
Of Oncology Nursing, 19(1), 16-19.
Chakraborty, A., Wells, R., Doherty, M., Huynh, C., & Selby, D. (2008). Joint Pain in
AML: Successful Pain Control with Radiotherapy. Journal Of Pain & Symptom
Management, 35(6), 670-672.
Ferrara JL, Yanik G. Acute graft versus host disease: pathophysiology, risk factors,
and prevention strategies.Clin Adv Hematol Oncol. 2005 May. 3(5):415-9,
428.
Galway, K., Black, A., Cantwell, M., Cardwell, C.R., Mills, M., & Donnelly, M. (2012).
Psychosocial interventions to improve quality of life and emotional wellbeing
for recently diagnosed cancer patients. Cochrane Database of Systematic
Reviews, 11.
Harris, D.J. (2010). Transplantation. In J. Eggert (Ed.). Cancer basics. Pittsburgh:
Oncology Nursing Society.
Hinkle, J.L., & Cheever, K.H. (2014). Brunner & Suddarth’s Textbook of MedicalSurgical Nursing (13th ed.). Philadelphia: Lippincott Williams &
Wilkins.
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Holland, J. (1977). Psychological aspects of oncology. Medical Clinics of North
America, 61, 737-748.
Jamil, M. O., & Mineishi, S. (2015). State-of-the-art acute and chronic GVHD
treatment. International Journal Of Hematology, 101(5), 452-466.
Lowenberg, B., Downing, J. R., & Burnett, A. (1999). Acute myeloid leukemia. New
England Journal of Medicine, 341(14), 1051-1062.
National Cancer Institute. (2012a). General information about adult acute myeloid
leukemia.
Nerenz, D.R., Leventhal, H., & Love, R.R. (1982). Factors contributing to emotional
distress during cancer chemotherapy. Cancer, 50, 1020-1027.
Sommer, S., Johnson, J., Roberts, K., Redding, S. R., Churchill, L., Ball, B.,
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N. J., Leehy, P., & Roland, P. (2013). RN Adult Medical Surgical Nursing (9th ed).
Weisman, A.D., & Worden, J.W. (1976). The existential plight in cancer: Significance
of the first 100 days. International Journal of Psychiatry in Medicine, 7, 1-15.
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Williams, L. “Comprehensive Review of Hematopoiesis and Immunology:
Implications for Hematopoietic Stem Cell Transplant Recipients” in
Ezzone, S. (2004) Hematopoietic Stem Cell Transplantation: A Manual
Nursing Practice Oncology Nursing Society: Pittsburgh, PA
for