Leukemia is a malignant disease (cancer) of the bone marrow and blood.

It is characterized by the uncontrolled accumulation of blood cells. Leukemia is

divided into four categories: myelogenous or lymphocytic, each of which can be
acute or chronic. The terms myelogenous or lymphocytic denote the cell type
involved. There are four major types of leukemia. Leukemia is the general term
used to describe four different disease-types called:
• Acute Myelogenous Leukemia (AML)
• Acute Lymphocytic Leukemia (ALL)
• Chronic Myelogenous Leukemia (CML)
• Chronic Lymphocytic Leukemia (CLL)
The terms lymphocytic or lymphoblastic indicate that the cancerous
change takes place in a type of marrow cell that forms lymphocytes. The terms
myelogenous or myeloid indicate that the cell change takes place in a type of
marrow cell that normally goes on to form red cells, some types of white cells,
and platelets. Acute lymphocytic leukemia and acute myelogenous leukemia are
each composed of blast cells, known as lymphoblasts or myeloblasts. Acute
leukemias progress rapidly without treatment. Chronic leukemias have few or no
blast cells. Chronic lymphocytic leukemia and chronic myelogenous leukemia
usually progress slowly compared to acute leukemias.

In chronic myelogenous leukemia (CML), the leukemia cell that starts the
disease makes blood cells (red cells, white cells and platelets) that function
almost like normal cells. The number of red cells is usually less than normal,
resulting in anemia. CML starts with a change to a single stem cell. CML patients
have what is called the "Philadelphia Chromosome" (Ph chromosome).
Chromosomes are structures in the cells that contain genes. Every cell with a
nucleus has chromosomes. Genes give instructions to the cells. The Ph
chromosome is made when a piece of chromosome 22 breaks off and attaches

1
to the end of chromosome 9. A piece of chromosome 9 also breaks off and
attaches to the end of chromosome 22.

From 2003-2007, the median age at diagnosis for chronic myeloid

leukemia was 65 years of age. Approximately 2.5% were diagnosed under age
20; 7.4% between 20 and 34; 10.1% between 35 and 44; 13.3% between 45 and
54; 15.0% between 55 and 64; 19.0% between 65 and 74; 22.7% between 75
and 84; and 9.9% 85+ years of age. The age-adjusted incidence rate was 1.5 per
100,000 men and women per year. These rates are based on cases diagnosed
in 2003-2007 from 17 SEER geographic areas. (SEER, National Cancer Institute,
2009)

Both children and adults can get CML, but most CML patients are
adults. About 1,458 in the Philippines are expected to be diagnosed with chronic
myelogenous leukemia (CML).
There are three phases of CML:
1. Chronic Phase CML
Most patients are in the chronic phase of the disease when their CML is
diagnosed. In this phase, CML symptoms are milder. White cells can still fight
infection. Once patients in the chronic phase are treated, they can go back to
their usual activities.
2. Accelerated Phase CML
In the accelerated phase, the patient may develop anemia, the number of
white cells may go up or down, or the number of platelets may drop. The number
of blast cells may increase and the spleen may swell. People with accelerated-
phase CML may feel ill.
3. Blast Crisis Phase CML
Patients with blast crisis phase CML have an increased number of blast
cells in the marrow and blood. The number of red cells and platelets drops.
Patients may have infections or bleeding. They may also feel tired and have
shortness of breath, stomach pain, or bone pain.

2
 People with CML may not have any symptoms at the time of diagnosis.
They may be diagnosed following a medical examination for another condition or
as part of a periodic checkup. CML signs and symptoms tend to develop
gradually. Some signs and symptoms of CML are:
• Tiring more easily
• Shortness of breath doing usual day-to-day activities
• Pale skin color
• Enlarged spleen leading to a "dragging" feeling on the upper left side of
the abdomen
• Night sweats
• An inability to tolerate warm temperatures
• Weight loss.
Many of the signs and symptoms for CML are common to other illnesses.
Most people with these signs and symptoms do not have CML.

Objective of the Study

This case study aims to improve the present condition of the patient and
conducted to gain a thorough understanding concerning the case. And to apply
students’ knowledge on nursing assessment, problem identification, nursing
interventions and evaluation that is related to the disease condition.
This study also aims to improve the skills of a student in clinical area,
interpersonal relationship with the patient and other health care givers and to
gain more confidence. It also aims to help the patient to solve or reduce his
illness. As nursing students, we impart knowledge of what we have learned in
school and practice that acquired learning’s to become an effective nurse
someday. One way to improve our skills is to help patients with their health
problems or illness and applying simple interventions.

The specific objectives of this study are at the end of 2 weeks in Sabal hospital,
we will be able to:

1. Establish rapport to our chosen patient for the Care study.

3
 2. Identify and appraises health problem of the patient.
3. Provides nursing services according to health needs of the patient
4. Helps to develop the competency in the members to take care and when
required and to find out remedial measures to solve health problems.

Scope and Limitation of the Study

This study includes the collection of information specific to the patients’
health condition primarily about the said case. The study also comprises the
assessment of the physiological and emotional status, adequacy of support
systems, and care given by the family as well as other health care providers.
However, the study is limited by the following:
 Days of care only lasted for 2 days of clinical duty
 The data gathered based from the client’s chart and the
verbalizations of the client and his significant other’s.
 Home visits were not done due to the distance of the client’s home
 Consultation with the patient’s attending physician for additional
data about his current condition were not done.
 This study focuses on determining the patient’s main concern or
problems

4
Patient’s Profile

Name: Mr. Piolo

Age: 62 years old

Gender: Male

Civil Status: Widower

Birthday: November 4, 1948

Height: 5’5

Weight: 58 kg

Nationality: Filipino

Religion: Roman Catholic

Educational Attainment: College Graduate

Occupation: Retired Soldier

5
Pension: 7-10,000 per month

Address: 670 Mabini Burgos, Brgy.13 CDOC

Date of admission: June 30, 2010

Time of admission: 3:05 pm

Chief complaint: Pallor and Dyspnea

Attending physician: Dr. Queja

Admitting Diagnosis: Chronic Myelogenous Leukemia

Family and Personal History

Mr. Piolo, Male, Filipino, 62 years old, is a resident of Mabini, Burgos,
Cagayan de Oro City. He has received all vaccinations during his childhood
years. He has a family history of hypertension on both mother and father side.
And he has no known drug and food allergies. He graduated at the University of
Bohol in a Bachelor’s Degree of Political Science. He worked as a soldier based
here in the Philippines.
At present, Mr. Piolo is a retired soldier and is independent from his
children. He receives his pension of 7,000 to 10,000 per month. He is a widower
of Mrs. Decir, and they had three (3) children. His eldest, Maris, is a nurse in one
of the school’s here in Cagayan de Oro. His middle and youngest children,
Charito and Mae, are now in college pursuing their course of choice in one of the
prestigious school’s here in Cagayan de Oro.
Mr. Piolo had an accident during his teenage years while driving his
motorcycle. But he was not admitted because he only acquired skin abrasions
from the accident.
History of Present Illness:
3 years prior to admission, Mr. Piolo’s friend, a doctor, noticed that he
was very pale. The doctor suggested that he should undergo a laboratory exam,

6
CBC. After the result is in, it shows that Mr. Piolo has low Hemoglobin,
Hematocrit and RBC count. After the results, the doctor referred Mr. Piolo to Dr.
Queja for further assessment. The patient underwent another examination, which
led to Dr. Queja’s diagnosis of leukemia. From the time of referral and up to the
present, Mr. Piolo is undergoing therapy to improve his condition. His laboratory
examination, CBC, is scheduled every month and his blood transfusion therapy is
scheduled every two (2) months and
Last April 2010, the patient was admitted in Sabal hospital for blood
transfusion as one of the management for his condition. Last, June 29,1010; the
patient had a CBC exam at Sabal hospital, the result showed that he had low
Hemoglobin, Hematocrit and RBC, Dr. Queja the prompted to admit the patient
the next day for the need of blood transfusion.

A. Erick Erickson (Psychosocial Theory)

Mr. Piolo’s age belongs to the adulthood stage of Erik Eriksson’s theory of stages
of development. The central task that he ought to resolve at this stage is to resolve
generativity versus stagnation. With Mr. Piolo’s case, he verbalized that drinking and
smoking is very bad in our health. With this, he was able to accept one’s own life’s
uniqueness and worth. The patient shows signs of positive resolution because whenever
he was asked to do something he is very eager to cooperate and respond to the questions
given to him. Furthermore, he also said that he was happy to raise his children and watch
them grow with their respective families now. He also verbalized that he is not afraid to
die at this point in his life because according to him, his task of being a father to his
children and a husband to his wife has been done.

B. Jean Piaget (Cognitive Developmental Theory)

7
 It refers to the manner in which people learn to think, and use language. It
involves a person’s intelligence, perceptual ability, and ability to process information.
Cognitive development represents a progression of mental abilities from illogical to
logical thinking, from simple to complex problems solving, and from understanding
concrete ideas to understanding abstract concepts.

As we observed, Mr. Piolo could talk and communicate well able to answers our
questions correctly, he was still able to think logically and he lives with his good moral
standards.

C. Robert Havighurst (Developmental Task)

According to Robert Havighurst’s Developmental Theory, the client belongs to

the late maturity stage wherein in there is adjustment to decreasing physical strength and
health. There’s an adjustment to retirement and reduced income. Establishing an explicit
affiliation with one’s age group is one of the major highlights of this stage. Adopting and
adapting social roles in a flexible way. Establishing satisfactory physical living
arrangements which are all held true to the client. Since he had his retirement, he was
able to adjust to the life he is having now especially with the death of his spouse, and is
even open to the possibilities that might happen, like things beyond our control.

D. Sigmund Freud (Psychosexual Theory)

According to Freud’s psychosocial theory, he belongs to the Genital Stage. During this
final stage of psychosexual development, the individual develops a strong sexual interest
in the opposite sex. Where in earlier stages the focus was solely on individual needs and,
interest in the welfare of others grows during this stage. If the other stages have been
completed successfully, the individual should now be well-balanced, warm, and caring.

8
And this is true to the client. The client was very warm and caring, as verbalized by her
grand children and daughter. Although he lost already that sexual urge towards the
opposite sex, he was able to fulfill those things during the earlier stage of his married life.

NURSING SYSTEM REVIEW CHART

Vital Signs:
Pulse: 76bpm BP: 100/80mmHg Temp: 35.7C RR: 18 Height: 5’5 Weight: 58kg
EENT:
 impaired vision □ blind
Asses eyes, ears, nose
throat for abnormality □no problem
RESP: dry lips(7/1/10)
□ asymmetric □ tachypnea
□ apnea □ rales □ cough □ barrel chest Non productive dry
cough(7/1/10)
□ bradypnea □ shallow □ rhonci
□ sputum □ diminished □ dyspnea
□ orthopnea □ labored □ wheezing body weakness(7/1/10)
□ pain □ cyanotic
Asses resp, rate, rhythm, depth, pattern,
breath sounds, comfort  no problem pale nailbeds(7/1/10)
CARDIO VASCULAR
□ arrhythmia □ tachycardia □ numbness
□ diminished pulses □ edema  fatigue
□ irregular □ bradycardia □ murmur
□ tingling □ absent pulses □ pain
Asses heart sounds, rate rhythm, pulse, blood dark scars and few small wounds
pressure, clrc., fluid retention, comfort
no problem
GASTRO INTESTINAL TRACT
□ obese distention □ mass
□dysphagia □ rigidly □ pain
Asses abdomen, bowel habits, swallowing,
bowel sounds, comfort □ no problem
GENITO-URINARY and GYNE
□ pain □ urine color □ vaginal bleeding
□ hermaturia □ discharge □ noctoria
Asses urine freq., color, control, odor, comfort/

9
Gyne-bleeding, discharge  no problem dry skin
NEURO
□ paralysis □ stuporous □ unsteady □ seizures
□ lethartic □ comatose □ vertigo □ tremors
□ confused □ vision □ grip
Asses motor function, sensation, LOC, strength, IVF #01 PNSS 1L at
10gtts/min
Grip, galt, coordination, orientation, speech, IVF #02 PNSS 1L at
10gtts/min
 no problem
MUSCULOSKELETAL and SKIN BT #02 at 25gtts/min (July
01, 2010)
□ appliance □ stiffness  itching □ petechiae BT #03 at 25gtts/min (July
01, 2010)
□ hot □ drainage □ prosthesis □ swelling BT #04 at 25gtts/min (July
02, 2010)
□ lesion □ poor turgor □ cool □ deformity
□ wound □ rash □ skin color □ flushed
□ atrophy □ pain □ ecchymosis
□ diaphoretic □ moist
Asses mobility, motion. Galt, alignment, joint function
/skin color, texture, turgor, integrity □ no problem

June 30, July 01, 2010 July 01, 2010 3PM- July 02, 2010
2010 7AM-3PM Nursing Assessment
11PM II 11PM-7AM

10
 SUBJECTIVE OBJECTIVE
Comments:
COMMUNICATIO [x] glasses [ ] languages
“ Wala man,
N: [ ] contact lens [ ] hearing aid [
maayo man akong
] speech diff.
pandungog”
[ ] hearing loss “Gagamit ko ug
Pupil: R = 3mm L = 3mm
[x] visual changes reading glasses,
Reaction: Pupils Equally Round and
[ ] denied nearsighted man
Reactive to Light and Accomodation
gud ko.”
Comments:” atong
SUBJECTIVEulitawo pako OBJECTIVE
SKIN INTEGRITY: gasigarilyo
Comments: ko, [x] dry [ ]cold [ ]
OXYGENATION:
[x] dry wala
“ katol usahay ni pale
[x]
[ ]itching
dyspnea naman
akongdayon”
tiil mao Resp.
[ ] flushed[x] regular
[ ]warm [ ] irregular
[ [x] smoking history ganing
] other hangos
nayko pag
mga Describe:
[ ] moist the pt. respiration
[ ]cyanoticis regular
[ [x]
] denied
cough dugay2
pali-pali
na kay
baklay
ga and has an equal lung expansion.
[ ] sputum kanang
katulonganako.”
apason R Symmetrical
rashes, ulcers,todecubitus
left
[ ] denied ang ginhawa” L(describe
Symmetrical
size,tolocation,
right drainage)
gi ubo lng ko karon scars on both legs, dark in color,
kay nag inum kog different sizes, small wounds
ACTIVITY/ SAFETY: bugnaw tubig.
Comments:
[ ] convulsion “ga walking [ ] LOC and orientation:
[ ] dizziness gani ko or ga Heart Rhythmalert
Pt is awake, [x] and
regular [ ] irregular
oriented to
[ ]limited motion jogging” Ankle
time, date,
Edema andnone
place
Comments:
CIRCULATION:
of joints wala man koy Gait: [ ] walker [ ] cane [ ] other
“usahay maminhod
[ ] chest pain limitasyon sa Pulse Car. Rad. DP Fem*
akong mga tudlo
[ ] leg pain
Limitation in ability to pag lihok-lihok R 78
[x] steady [ ]76 pulses ______
unsteady present in
dili ma straight”
[ [x] numbness of
] ambulate basta dili all
[ ]area
sensory and motor losses in face
extremities
[ [ ]] bathe
deniedself lang ga ubos L 78 76no pulses
or extremities: motor present
losses inin
[ ] other akong dugo.”
all
facearea
[x] denied
Comments: normal heart
[ ] ROM limitations: rhythm
active movement
NUTRITION:
of body parts.
Diet: Diet as
COMFORT/SLEEP/A Comments:
Comments:”“ dili
tolerated
WAKE: nawala
pareha
may [[ ]] dentures
facial grimace [x] none
[]N []V
[ ] pain sauna akong gana
problema, [ ] guarding
Character
(location, frequency, sa normal lang jud [ ] other signsFull
of pain:
Partial
No pain noted.
[x] recent change
remedies) nahimong 58kg”
basta edad- incomplete
in weight, appetite
[ ] nocturia pagkaun,
edaran from
na dili Upper [ ] [ ] [ x ]
[ ] swallowing
[ ] sleep difficulties 72kg
kayo taas ang Lower [ ] [ ] [ x ]
difficulty
[x ] denied tulog”
[ ] denied
COPING:
Observed non-verbal behavior:
Occupation:
ELIMINATION: retired soldier
smiling, closing eyes, tearfulness,
Usual bowel
Members of Household: 3 vigilance, hand and arm movements
pattern
Most
Every Supportive
other dayPerson: Daughter
urinary frequency
5-8 times a day Bowel Sounds
[ ] constipation 10/min
remedy [ ] urgency Comments: normoactive
pt. has no [ ] dysuria The patient has no
remedies [ ] hematuria problems with Abdominal
[ ] incontinence bowel and urine Distention: none
Date of Last BM: [ ] polyuria elimination.
June 29, 2010 [x] foly in place Urine
[ ] denied Rusty, aromatic
[ ] diarrhea
character
No diarrhea

MGT. OF HEALTH ILLNESS: Briefly describe the pt.’s ability to

[ ] alcohol [x] denied follow treatments (diet, meds, etc.)
(amount, frequency) for chronic health problems (if
sauna ulitawo ko ga inum ko, sukad ato present).
wala na. Kapoy lang ni nasakit kay The patient follows his medications. 11
atimanun jud. Hasol kay pirmi ra sa Comply on blood transfusion. The
balay gapuyuay” _ patient takes all medicines prescribed.
12
Doctor’s Order with Rationale
Date/ Time Order
June 30,2010 • Admit under my service
3:05pm
• TPR q 4, I & O q shift, Vital
signs q 4
• IVF PNSS 1L @ 10gtts/min
• Lab attached to CBC
• Transfuse 4units PRBC
properly, type and cross-
match each unit to run for 4
hour with 4 hour interval in
between each unit
• Premeds for every 2units
PRBC:
1. PCM 500mg; tab
2. Benadryl 50mg; cap
• Watch out for BT reaction
• Congestion precaution
• Inform me once admitted
July 1, 2010
3pm • PNSS 1L @ 10gtts/min
July 2, 2010 • May go home
• Repeat CBC after 1month
• Continue Glivek
Rationale
• For proper management
and by request of the
patient since the doctor
is specialized in the field
• For monitoring patient’s
health status
• For preparation for blood
transfusion, it is the only
solution compatible for
BT
• Basis in planning for
treatment, indication for
BT
• To compensate for low
RBC, hemoglobin, and
hematocrit count of the
patient’s CBC exam
result
• To prevent /treat side
effects of BT such as
itchiness, increased
body temperature and
chilling
• To prevent allergic
reaction
• Client is CML, chronic
phase
• To allow physician make
plans during admission
• Used for flushing in BT
• Patient has consumed
4units of PRBC, which is
his main purpose to be
admitted
• To check the current
status of patient’s blood
components and for
examination
• For treatment of the
disease
13
Drug Study

Generic Name Imatinib mesylate

Brand Name Glivec
Date Ordered Last morning
Classification Protein Tyrosine Kinase Inhibitor, Antineoplastic
Dose/ Frequency/
100 mg BID P.O
Route
Mechanism of A protein-tyrosine kinase inhibitor which potently inhibits
the breakpoint cluster region-Abelson (Bcr-Abl) tyrosine
Action kinase at the in vitro, cellular, in vivo levels.
Treatment of adult and pediatric patients with newly
diagnosed chronic myeloid leukemia (CML) as well as
Specific Indication
those with CML in blast crisis, accelerated phase, or in
chronic phase after failure of interferon-α therapy
• Hypersensitivity to imatinib or to any of the
Contraindication
excipients of Glivec.
• Fluid retention
• Muscle cramps or pain
• Abdominal pain
• Vomiting
• Diarrhea
Side Effects
• Hemorrhage (abnormal bleeding)
• Nausea
• Fatigue
• Rash

• Should be taken with food and a large glass of water

Nursing to minimize the risk of GI disturbances.
Precaution • Use prescription as directed, even if feeling better.
• Take this medicine at a similar time of day.

14
Generic Name of
Multivitamin
the Ordered Drug
Brand Name Centrum, Stresstabs, Conzace, etc.
Date Ordered Maintenance drug
Classification Vitamins and minerals
Dose/ Frequency/
500 mg once daily
Route
That boosts the body's immune system. It protects against
Mechanism of
vitamin C deficiency and enhances the body's resistance
Action
to stress, the common cold and some types of infections.
Treatment and prevention of vitamin C deficiency,
boosting of the body's immune system, resistance to
Specific Indication
colds and infections, speeding up of wound healing and
maintenance of healthy teeth, bones and gums.
Contraindication • Hypersensitivity to any of its components.
Severe allergic reactions (rash; hives; itching; difficulty
breathing; tightness in the chest; swelling of the mouth,
Side Effects face, lips, or tongue).

Nursing Precaution • May be taken with or without food

Generic Name Paracetamol

Brand Name Biogesic
Date Ordered June 30, 2010
Classification Antipyretic
Dose/ Frequency/
500 mg; tab (premeds for every 2 units of PRBC)
Route
Mechanism of Reduces fever by acting directly on the hypothalamic heat
Action regulatory center

15
Specific Indication For fever
Contraindication • Allergy to drug, to impaired hepatic function
Side Effects • Headache
• Do not exceed recommended dosage
• Check temperature before giving the medication
Nursing Precaution
and after giving the medication
• Give drug with food

Generic Name Diphenhydramine hydrochloride

Brand Name Benadryl
Date Ordered June 30, 2010
Classification Antihistamine
Dose/ Frequency/
500 mg; cap (premeds for every 2 units of PRBC)
Route
Mechanism of Competitively blocks the histamine at H receptor sites,
Action has atropine like antipruritic and sedative effects
Specific Indication Amelioration of allergic reactions to blood
Allergy to any antihistamines, asthmatic attack, stenosing
Contraindication
peptic ulcer
Dizziness Drowsiness
Side Effects
Dry mouth Sedation
• Administer with food
Nursing Precaution • Monitor patient response
• Avoid excessive dosage
Laboratory Results with Implications

16
Diagnostic Exam Results Normal values Significance of the result
CBC
6/29/10
White blood cells 4500mm 5,000-10,000/mm At risk of infection

Red blood cells 2.49 4.35-5.90 mil/mm Indication of anemia

Hemoglobin 7.3 13.7-16.7 g/dl Indication of anemia

Hematocrit 21.9 40.5-49.7vols% Indication of severe anemia

Platelet 1,398,000 144,000-372,000 Malignancy

MCV 88.0 79.7-97.0 u Normal range

MCH 29.2 26.1-33.3pg Normal range

Differential count
Neutophils 36 43.4-76.2% Decreased probably
because of bone marrow
disease

Lymphocytes 39 17.4-46.2% Normal range

Monocytes 24 4.5-10.5% Increased probably due to

hemolytic disorders

Eosinophils 01 2-3% Decreased with stress use

of medications

17
A. Skeletal System
The skeleton has five major functions. These are:

• Support - the body is kept in

position by the muscles that
attach to the skeleton.
• Protection- the flat bones
protect the internal organs.
• Movement - provided by the
joints
• Production of Blood - blood
cells are produced in the red
bone marrow in the centre of
some bones, including the
pelvis, ribs, vertebrae and
stenum. The yellow bone
marrow stores fat. The yellow
bone marrow can convert to
red bone marrow if the body
needs additional blood
production.
• Storage - Minerals are stored
in the bone, mostly calcium
and phosphorus.

The Spinal Column

18
The spinal column is made up of 33 vertebrae, in a 7-12-5-5-4 combination, as
can be seen from the diagram below. Note that the 5 vertebrae in the sacrum
and the 4 vertebrae in the coccyx are fused. Note also that the spine is curved,
and these curves act as shock absorbers.

The spine may become stressed if these curves are altered.

B. Cardiovascular System
Knowing the functions of the cardiovascular system and the parts of the
body that are part of it are critical in understanding the physiology of the human
body. The cardiovascular system is the system that keeps life pumping through
you with its complex pathways of veins, arteries, and capillaries. The heart, blood
vessels, and blood help to transport vital nutrients throughout the body as well as
remove metabolic waste. They help to protect the body and regulate body
temperature.

The cardiovascular system consists of the heart, blood vessels, and blood.
This system has three main functions:
• Transport of nutrients, oxygen, and hormones to cells throughout the body
and removal of metabolic wastes (carbon dioxide, nitrogenous wastes,
and heat).
• Protection of the body by white blood cells, antibodies, and complement
proteins that circulate in the blood and defend the body against foreign
microbes and toxins. Clotting mechanisms are also present that protect
the body from blood loss after injuries.
• Regulation of body temperature, fluid pH, and water content of cells.

Blood Formation
Hemopoiesis (hematoiesis) is
the process that produces the
formed elements of the blood.

19
Hemopoiesis takes place in the red bone marrow found in the epiphyses of long
bones (for example, the humerus and femur), flat bones (ribs and cranial bones),
vertebrae, and the pelvis. Within the red bone marrow, hemopoietic stem cells
(hemocytoblasts) divide to produce various “blast” cells. Each of these cells
mature and becomes a particular formed element.

Erythropoiesis
Erythropoiesis, the process of making erythrocytes, begins with the
formation of proerythroblasts from hemopoietic stem cells. Over three to five
days, several stages of development follow as ribosomes proliferate and
hemoglobin is synthesized. Finally, the nucleus is ejected, producing the
depression in the center of the cell. Young erythrocytes, called reticulocytes, still
containing some ribosomes and endoplasmic reticulum, pass into the
bloodstream and develop into mature erythrocytes after another one or two days.

Erythroprotein
Erythroprotein (EPO), a hormone produced mostly by the kidneys,
stimulates bone marrow to produce erythrocytes. When inadequate amounts of
oxygen are delivered to body cells, a condition called hypoxia, the kidneys
increase EPO secretion, which, in turn, stimulates an increase in erythrocyte
production.
The average production rate of erythrocytes in healthy individuals is two
million cells per second. Normal production requires adequate amounts of iron
and vitamin B12 and folic acid.

Leukopoiesis
Leukopoiesis, the process of making
leukocytes, is stimulated by various colony-
stimulating factors (CSFs), hormones produced
by mature white blood cells. The development

20
of each kind of white blood cell begins with the division of themopoietic stem cells
into one of the following “blast” cells.
• Myeoblasts divide to form eosinophilic, neutrophilic, or basophilic
myelocytes, which lead to the development of the three kinds of
granulocytes.
• Monoblasts lead to the development of monocytes.
• Lymphoblasts lead to the development of lymphocytes.

Thrombopoiesis
Thrombopoiesis, the process of making platelets, begins with the
formation of megakaryoblasts from hemopoietic stem cells. The megakaryoblasts
divide without cytokinesis to become megakaryocytes, huge cells with a large,
multilobed nucleus. The megakaryocytes then fragment into segments as the
plasma membrane infolds into the cytoplasm.

C. Lymphatic System
An important supplement to the cardiovascular system in helping to
remove toxins from the body, the lymphatic system is also a crucial support of
the immune system. Unlike blood, lymph only moves one way through your body,
propelled by the action of nearby skeletal muscles. The lymph is pushed into the
bloodstream for elimination. Appreciating the importance of the lymphatic system
in filtering, recycling, and producing blood as well as filtering lymph, collecting
excess fluids, and absorbing fat-soluble materials is important in the
understanding of human physiology.

The lymphatic system consists of lymphatic vessels, a fluid called lymph,

lymph nodes, the thymus, and the spleen . This system supplements and
extends the cardiovascular system in the following ways:

• The lymphatic system collects excess fluids and plasma proteins from
surrounding tissues (interstitial fluids) and returns them to the blood
circulation. Because lymphatic capillaries are more porous than blood

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 capillaries, they are able to collect fluids, plasma proteins, and blood cells
that have escaped from the blood. Within lymphatic vessels, this collected
material forms a usually colorless fluid called lymph, which is transported
to the neck, where it empties into the circulatory system.

• The lymphatic system absorbs lipids and fat-soluble materials from the
digestive tract.

• The lymphatic system filters the lymph by destroying pathogens,

inactivating toxins, and removing particulate matter. Lymph nodes, small
bodies interspersed along lymphatic vessels, act as cleaning filters and as
immune response centers that defend against infection.

The movement of lymph through lymphatic vessels is slow (3 liters/day)

compared to blood flow (about 5 liters/minutes). Lymph does not circulate like
blood, but moves in one direction from its collection in tissues to its return in the
blood. There are no lymphatic pumps. Instead, lymph, much like blood in veins,
is propelled forward by the action of the nearby skeletal muscles, the expansion
and contraction of the lungs, and the contraction of the smooth muscle fibers in
the walls of the lymphatic vessels. Valves in the lymphatic vessels prevent the
backward movement of lymph.
Lymphatic Tissues and Organs
Lymphatic cells are organized into tissues and organs based upon how tightly
the lymphatic cells are arranged and whether the tissue is encapsulated by a
layer of connective tissue. Three general categories exist:
• Diffuse, unencapsulated bundles of lymphatic cells. This kind of lymphatic
tissue consists of lymphocytes and macrophages associated with a
reticular fiber network. It occurs in the lamina propria (middle layer) of the
mucus membranes (mucosae) that line the respiratory and gastrointestinal
tracts.

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 • Discrete, unencapsulated bundles of lymphatic cells, called lymphatic
nodules (follicles) . These bundles have clear boundaries that separate
them from neighboring cells. Nodules occur within the lamina propria of
the mucus membranes that line the gastrointestinal, respiratory,
reproductive, and urinary tracts. They are referred to as mucosa-
associated lymphoid tissue (MALT). The nodules contain lymphocytes and
macrophages that protect against bacteria and other pathogens that may
enter these passages with food, air, or urine. Nodules occur as solitary
nodules, or they cluster as patches or aggregates. Here are the major
clusters of nodules:
o Peyer's patches are clusters of lymphatic nodules that occur in the
mucosa that lines the ileum of the small intestine.
o The tonsils are aggregates of lymphatic nodules that occur in the
mucosa that lines the pharynx (throat). Each of the seven tonsils
that form a ring around the pharynx are named for their specific
region: A single pharyngeal tonsil (adenoid) in the rear wall of the
nasopharynx, two palatine tonsils on each side wall of the oral
cavity at its entrance in the throat, two lingual tonsils at the base of
the tongue, and two small tubal tonsils in the pharynx at the
entrance to the auditory tubes.
o The appendix, a small fingerlike attachment to the beginning of the
large intestine, is lined with aggregates of nodules.
• Encapsulated organs contain lymphatic nodules and diffuse lymphatic
cells surrounded by a capsule of dense connective tissue. The three
lymphatic organs are discussed in the following sections.

Lymph nodes
Lymph nodes are small, oval, or bean-shaped bodies that occur along
lymphatic vessels. They are abundant where lymphatic vessels merge to form
trunks, especially in the inguinal (groin), axillary (armpit), and mammary gland
areas. Lymph flows into a node through afferent lymphatic vessels that enter the
convex side of a node. It exits the node at the hilus, the indented region on the

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opposite, concave side of the node, through efferent lymphatic vessels. Efferent
vessels contain valves that restrict lymph to movement in one direction out of the
lymph node. The number of efferent vessels leaving the lymph node is fewer
than the number of afferent vessels entering, slowing the flow of lymph through
the node.
Lymph nodes perform three functions:
• They filter the lymph, preventing the spread of microorganisms and toxins
that enter interstitial fluids.
• They destroy bacteria, toxins, and particulate matter through the
phagocytic action of macrophages.
• They produce antibodies through the activity of B cells.

The structure of a lymph node is characterized by the following features:

• A capsule of dense connective tissue surrounds the lymph node.
• Trabeculae are projections of the capsule that extend into the node
forming compartments. The trabeculae support reticular fibers that form a
network that supports lymphocytes.
• The cortex is the dense, outer region of the node. It contains lymphatic
nodules where B cells and macrophages proliferate.
• The medulla is the center of the node. Less dense than the surrounding
cortex, the medulla primarily contains T cells.
• Medullary cords are strands of reticular fibers with lymphocytes and
macrophages that extend from the cortex toward the hilus.
• Sinuses are passageways through the cortex and medulla through which
lymph moves toward the hilus.

Thymus
The thymus is a bilobed organ located in the upper chest region between
the lungs. It grows during childhood and reaches its maximum size of 40 g at
puberty. It then slowly decreases in size as it is replaced by adipose and areolar
connective tissue. By age 65, it weighs about 6 g.

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Each lobe of the thymus is surrounded by a capsule of connective tissue.
Lobules produced by trabeculae (inward extensions of the capsule) are
characterized by an outer cortex and inner medulla. The following cells are
present:
• Lymphocytes consist almost entirely of T cells.
• Epithelial-reticular cells resemble reticular cells, but do not form reticular
fibers. Instead, these star-shaped cells form a reticular network by
interlocking their slender cellular processes (extensions). These
processes are held together by desmosomes, cell junctions formed by
protein fibers.
• Epithelial-reticular cells produce thymosin and other hormones believed to
promote the maturation of T cells.
• Thymic (Hassall's) corpuscles are dense, concentric layers of epithelial-
reticular cells. Their function is unknown.

The function of the thymus is to promote the maturation of T lymphocytes.

Immature T cells migrate through the blood from the red bone marrow to the
thymus. Within the thymus, the immature T cells concentrate in the cortex where
they continue their development. Mature T cells leave the thymus by way of
blood vessels or efferent lymphatic vessels, migrating to other lymphatic tissues
and organs where they become active (immunocompetent) in immune
responses. The thymus does not provide a filtering function similar to lymph
nodes (there are no afferent lymphatic vessels leading into the thymus), and
unlike all other centers of lymphatic tissues, the thymus does not play a direct
role in immune responses.
Blood vessels that permeate the thymus are surrounded by epithelial-reticular
cells. These cells establish a protective blood-thymus barrier that prevents the
entrance of antigens from the blood and into the thymus where T cells are
maturing. Thus, an antigen-free environment is maintained for the development
of T cells.

Spleen

25
 Measuring about 12 cm (5 in) in length, the spleen is the largest lymphatic
organ. It is located on the left side of the body between the diaphragm and
stomach. Like other lymphatic organs, the spleen is surrounded by a capsule
whose extensions into the spleen form trabeculae. The splenic artery, splenic
vein, nerves, and efferent lymphatic vessels pass through the hilus of the spleen
located on its slightly concave, upper surface. There are two distinct areas within
the spleen:
• White pulp consists of reticular fibers and lymphocytes in nodules that
resemble the nodules of lymph nodes.
• Red pulp consists of venous sinuses filled with blood. Splenic cords
consisting of reticular connective tissue, macrophages, and lymphocytes
form a mesh between the venous sinuses and act as a filter as blood
passes between arterial vessels and the sinuses.

The functions of the spleen include the following:

• The spleen filters the blood. Macrophages in the spleen remove bacteria
and other pathogens, cellular debris, and aged blood cells. There are no
afferent lymphatic vessels and, unlike lymph nodes, the spleen does not
filter lymph.
• The spleen destroys old red blood cells and recycles their parts. It
removes the iron from heme groups and binds the iron to the storage
protein.
• The spleen provides a reservoir of blood. The diffuse nature of the red
pulp retains large quantities of blood, which can be directed to the
circulation when necessary. One third of the blood platelets are stored in
the spleen.
• The spleen is active in immune responses. T cells proliferate in the white
pulp before returning to the blood to attack nonself cells when necessary.
B cells proliferate in the white pulp, producing plasma cells and antibodies
that return to the blood to inactivate antigens.
• The spleen produces blood cells. Red and white blood cells are produced
in the spleen during fetal development.

26
27
IDEAL NURSING MANAGEMENT
NURSING GOALS INTERVENTI RATIONAL EVALUATION
DIAGNOSIS ON E

28
 Altered Nutrition: Less Short Term: Independent: After the Nursing
than Body Requirements Interventions, the
r/t decreased Intake and At the end of 1. Obtain a - Identifies goals were partially
loss of appetite 2 hours of thorough deficiencies/ met.
Nursing nutritional needs to aid in
Intervention, assessment. choice in 2days after the day of
client will be intervention. assessment, the
able to: 2. Provide a patient was
pleasant - Useful in discharged; the group
Display atmosphere at promoting was not able to
improved mealtime; appetite. evaluate the long
energy level remove term goal.
and increased noxious stimuli.
appetite. However, before he
3. Provide oral - A clean mouth was discharged, he
Long Term: hygiene before enhances has shown slight
meals. appetite. increase in energy
At the end of level.
at least 4. Provide the
24hours of feedings in the -May reduce
Nursing prescribed fatigue and thus
Interventions, amount and on enhance intake
client will be time. while preventing
able to: gastric
-demonstrate 5. Ambulate and distention.
nutritional increase
intake activity as - Helpful in
adequate to tolerated. expulsion of
meet flatus.
metabolic Reduction of
needs as abdominal
evidenced by distension
increased contributes to
weight overall recovery
and sense of
well- being and
decreases
possibility of
secondary
problems.

OBJECTIVE IMPLEMENTATION
NURSING DIAGNOSIS EVALUATION
S Intervention Rationale

29
Knowledge deficit Short-Term Independent After the Nursing
treatment related to At the 1.Provide 1. Provides interventions, the
unfamiliarity of treatment end of 8 information relevant goals were partially
and lack of resources hours of relevant to the knowledge. met. The patient and
Nursing situation. his SO were able to
interventions, verbalize
the patient 2.Identify 2. Establishes understanding of
and his SO information that the content to condition and
will be able needs to be be included. treatment.
to: remembered.
1. Verbalize 3.Begin with 3. Facilitates He also
understand information the learning. able to initiate
ing of his client already lifestyle changes and
condition knows and participate in
and move to what treatment regimen.
treatment. the client does
not know, 1. For continuity
progressing of care and to
2. Exhibit from simple to promote
increased complex. wellness.
interest/as Dependent
sume 1. Identify
responsibili available
ty for own community
learning resources and
and begin support groups
to look for (e.g. health
information center).
and ask
questions

30
Actual Nursing Management
“ ga hangos ko pag dugay2 na baklay kanang ga apason ang
S ginhawa”
· Low RBC, Hgb. Hct
O
· pale
Ineffective tissue perfusion related to low oxygen carrying
A capacity of RBC
At the end of 8hours the client will be able to improve
P appearance and tissue perfusion
Independent:

S No subjective cues
• Moderate High Back Rest
O · Low WBC
promote lung expansion for proper breathing
· Weak
• Instructed Range of Motion
· Pale
A Risk for Infection related to inadequate secondary defenses (decrease
Hgb and decrease WBC)
• hours,
P At the end of 12 the patient
Instructed will Exercises
Breathing be able to identify interventions to
reduce risk of infection and to understand the risk factors.
I It improves tissue circulation
Independent:

I •Place in a private room. Limit visitors as indicated.

To Dependent:
protect patient from potential sources of pathogens/infection.

• Blood
•Instructed Transfusion
proper handwashing

To to compensate
prevents cross with the low RBC,
contamination andhgb, hct count
reduces risk ofofinfection
the patient
CBC exam result and to supply enough blood needed in the
body.
•Proper hygiene

To protect• patient
Administer Glevek sources of pathogens/infection.
from potential

for Philadelphia
•Encourage deepchromosome positive (ph +) CML
breathing exercises

At the end skin

• Monitor 8 hours thenotify
patient improved his condition. He is not
E color, pallor
that pale, no signs and symptoms of SOB
Proliferation of WBC can reduce oxygen carrying capacity of the
blood.

At the end of 12hours, patient was able to identify interventions to reduce

risk of infection and to understand the risk factors. 31
E
32
Medication: The patient was instructed that compliance of taking the
medications would improve his condition and treat it in
the long run. He was instructed to continue taking Glivek
with the right dose, and at the right route. He was
instructed to comply in all the medications being allotted
for him or to maintain taking the drugs that are for
maintenance.
Exercise: During his stay in the hospital, the client was assisted in
doing ROM exercises to promote circulation; He was also
assisted in walking, when he would go to the bathroom.
Avoid strenuous activities to avoid over consumption of
oxygen. He can also perform activities of daily living with
minimal effort.
Treatment The patient was instructed to cooperate in planned
interventions for his condition. Cooperate with docto’rs
treatment plan such as routine and scheduled blood
transfusion, weekly check-up and monthly CBC exam.
He was also encouraged to ask question about his
condition and the treatment he was undergoing
Out Patient(Check- If discharge, the client was instructed to have a follow-up
up)
check up 1 week after discharge for evaluation of his
condition and his compliance to the home medications
given. He can have routine check-up to the hospital or to
the nearest health care center for his condition to be
monitored and evaluated. He was advised to repeat CBC
after 1 month.
Diet Diet as tolerated was advised by the doctor. Patient was
encouraged to take nutritious food rich in Vit.A, Iron and
minerals. For health maintenance and recovery

33
 He now has decreased physical, physiological and emotional coping mechanism. He is
more prone to infection and complication because of his increasing age. For this reason his body
is not at its optimum functioning which explains the poor prognosis.

Age
He is now at the peak age of his life. At this age, his organ and body function is not the
same before. At this age deteriorating organs are present. Some of it has decreased its function
level. With this info, you could say that his body won’t cope up easily with the treatment and
recovery; especially he has a rare disease condition at this age.

Medication and Compliance

Compliance to medication is vital for the prompt improvement of our patient’s condition.
His medications were being administered per orem. The client received a good prognosis for he
showed willingness to follow or comply with his medication treatment. But medication alone is not
enough for the recovery and treatment. The body should accept the treatment and should
improve his condition, but at his condition; he will be okey for now but later on his blood
components falls down and he will undergo again the same treatment.

Family Support
The patient’s family showed full emotional, physical, and financial support towards the
patient, thus, he is given a good rating in this criterion. The group observed how well the client’s
daughter personally took good care of him and attended to all of his needs during his entire stay
in the hospital. They also provided the patient with all his needs in the ward such as medications,
and other supplies as well.

In one analysis of several clinical studies, three different risk groups were identified
based on a prognostic scoring system that includes several variables: age, spleen size, blast
count, platelet count, eosinophil count and basophil count. In the lowest risk group, the median
survival time was 98 months. In the middle group, the median was 65 months, and in the highest
risk group, the median was about 42 months. Of all patients analyzed, the longest survival time
was 117 months. However, this study pre-dates the advent of treatments using targeted therapy.
A follow-up on patients using imatinib published in the New England Journal of Medicine shows
an overall survival rate of 89% after five years

34
 Determined recommended dietary plans and provided dietary education
as appropriate.
 Reinforced to patient the importance of keeping follow-up appointments
with the health care provider.
 Explained to the patient the rationale for, side effects of, importance of
taking medications as prescribed.
 Informed patient's parents/family/caretaker of pertinent food and drug
interactions.
 Implemented measures to the patient's family to improve compliance:
included significant others in all discharge teaching sessions.
 Encouraged questions and allowed more time for reinforcement and
clarifications of information provided.
 Provided written instructions regarding scheduled appointments with
health care provider, medications prescribed, and signs and symptoms to
report.
 Referred to the nearest health center for check-up and monitoring of
condition. But for emergency cases the patient was advised to go to the
nearest hospital for monitoring of condition.

35
 Prompt medical treatment coupled with quality nursing care; will improved
prognosis of the client diagnosed with chronic myelogenous leukemia

Thorough and accurate physical assessment enabled the students to

identify priority actual and potential problems and provide nursing interventions
appropriate for the client’s specific medical condition.

Furthermore, this study provided the students a venue to practice learned

skills and impart valuable health teachings to enhance client’s knowledge
regarding her health condition in order to prevent complications and hasten
recovery.

36
Besa, E.(Mar 16, 2010) Chronic Myelogenous Leukemia from
http://emedicine.medscape.com/article/199425-overview

Chronic myelogenous leukemia and related disorders: An overview. In: Lichtman

MA, et al. Williams Hematology. 7th ed. New York, N.Y.: McGraw-Hill;
2006.http://www.accessmedicine.com/content.aspx?aID=2148618. Accessed
Sept. 11, 2008.

Cliffs Notes(n.d) The Fastest way to learn. Lymphatic System Components from
http://www.cliffsnotes.com/study_guide/Lymphatic-System-
Components.topicArticleId-22032,articleId-21980.html#ixzz0tZxAy0PI

Doenges, M., Moorhouse M.F., Murr, A.(2008), Nurse’s Pocket

Guide:Diagnoses,Prioritized
Interventions, and Rationales. Philadelphia, Pennsylvania:F.A Davis Company

Integrative medicine and complementary and alternative therapies as part of

blood cancer care. The Leukemia & Lymphoma Society. http://www.leukemia-
lymphoma.org/attachments/National/br_1150734030.pdf. Accessed Sept. 17,
2008.

Medline Plus(2010) Chronic myelogenous leukemia from

http://www.nlm.nih.gov/medlineplus/ency/article/000570.htm

Nowell PC (2007). "Discovery of the Philadelphia chromosome: a personal

perspective". Journal of Clinical Investigation : 2033–2035.

Schull, P.,(2009), Nursing Spectrum Drug Handbook.USA. McGraw-Hill

Smeltzer, S., Bare, B.,(2004), textbook of Medical-Surgical Nursing. Philadelphia.

Lippincott Williams & Wilkins

Statistics by country for chronic myeloid leukemia(2010) from

http://www.cureresearch.com/c/chronic_myeloid_leukemia/stats-country.htm

The Leukemia & Lymphoma Society (n.d) Fighting Blood Cancers. Chronic
Myelogenous Leukemia. from http://www.leukemia-lymphoma.org/all_page.adp?
item_id=8501

Wikipedia(2010) Chronic Myelogenous Leukemia. from

http://en.wikipedia.org/wiki/Chronic_myelogenous_leukemia

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