AGE : 25 Years old
BIRTHDATE : March 14, 1989
SEX : Female
OCCUPATION : Nurse – Call Center Agent
40% – Significant Other (Mother)
20% – Patient

Patient is a diagnosed case of T-cell Acute Lymphocytic Leukemia since July 2014 and is undergoing chemotherapy with Lanase and Vincristine. She had a chest thoracotomy tube insertion on August 11, 2014 in her right lung at Cebu Velez General Hospital.

In January 2014, 7 months prior to admission, patient was diagnosed with Mediastinal Lymphoma and had a chest thoracotomy tube insertion in her left lung at Perpetual Succour Hospital.

One night prior to admission, patient had epigastric pain, burning type, with a pain score of 10 out of 10, radiating to the back, associated with 3 episodes of vomiting estimated to be 1/4 cup in amount per episode, usually salivary in contents.

On the day of admission, patient had persistent epigastric pain with 1 episode of vomiting with salivary contents, which prompted them to have a consultation with the attending physician. They were then advised for admission. Upon admission, patient had 2 episodes of vomiting at the emergency room estimated to be 1/4 cup in amount per episode.

The attending physician gave the following impressions:
1. T-cell Acute Lymphocytic Leukemia
2. Gastroesophageal Reflux Disease
3. R/O Acute Pancreatitis

A. General Appearance and Behavior

Patient appeared to be conscious, coherent, responsive and well oriented of her present condition. At times, she may become irritable and uninterested due to pain felt. The patient’s vital signs are the following: temperature of 36.70C, pulse rate of 80 beats per minute, respiratory rate of 24 breaths per minute and blood pressure of 100/70 mmhg.

Upon receiving the patient, she was pale-looking, bald, which is a side effect of chemotherapy, ectomorphic with body malaise and has guarding behavior at epigastric area of the abdomen. Facial grimacing was present due to pain. She reported a pain score of 5/10. She has a chest thoracotomy tube in the right lung which was attached to a leg bag.

B. Skin

The skin is uniformly brown in color but pale in all areas and parts of the body. However, ecchymosis was noted at the antecubital fossa due to frequent extraction of blood. Skin is dry, warm to touch, and free from any other lesions or abrasions. Except for the site of the chest tube thoracotomy, other areas of the body has intact skin. The face has non-pitting edema secondary to allergic reactions to medications. Significant other verbalized that this was not her original skin color. The patient used to have lighter complexion before undergoing chemotherapy.

C. Head and Face

The skull is normocephalic and symmetrical. It is aligned with the body and no lesions, nodules and masses noted. Facial features were edematous but facial movements were symmetrical.

D. Eyes and Vision

The eyebrows are very thin and symmetrically aligned with equal movement. Eyelids are intact and closes symmetrically. Sclera appears white without lesions. Palpebral conjunctiva was shiny, smooth and pale pink in color. There was no evidence of tenderness or swelling over the lacrimal gland. Cornea was transparent, with details of the iris visible. Pupils are black in color, equal in size at 2mm and rounded, reactive to light and accommodation.

E. Ear and Hearing

Ears are symmetrical to each other, free from lesions and unusual discharges. Patient is able to respond when asked at both near and far distance.

F. Nose and Sinuses

External nares are symmetrical. It is at the center of the face, non-tender and has no lesions or unusual discharges observed. Nasal septum is intact and in midline. Patient has no difficulty differentiating and identifying smells.

G. Mouth and Oropharynx

Lips appear pale and dry. Tongue is moist and free from lesions. Patient has complete set of teeth without veneers or dentures. Gag reflex is present.

H. Neck

Neck is in midline and is aligned with the body. It has good flexion, extension and turning of head.

I. Respiratory System

Chest is symmetrical, with the chest tube at right chest wall. Respirations are deep and diaphragmatic. Regularity are altered when in pain. Breath sounds are clear and there was no cough noted.

J. Cardiovascular System

Apical pulse is regular and audible in all 4 anatomical sites, no abnormal heart sounds heard upon auscultation. There is no jugular vein distention noted.

K. Peripheral Vascular System

Pulse rate is regular and strong on both upper and lower extremities. No suspected bulging vein on legs and calves observed. Limbs are not tender upon palpation. Capillary refill is 2 seconds. There is negative Homan’s Sign and claudication noted. Nails are normal.

L. Breasts and Axillae

Patient reported non-tenderness of both breasts. No abnormal discharges noted. However, a scar is noted at the mediastinum affecting some part of the breasts due to the presence of months ago.

M. Abdomen/ Gastrointestinal System

Patient verbalized pain on epigastric area and loss of appetite. Abdominal skin is intact and has normoactive bowel movements. Patient verbalized no difficulty in defecating, has regular bowel movement and usually defecates once a day or every other day. Stool is soft and brown in color.

N. Musculoskeletal System

Both upper and lower extremities are positive to flexion and extension. Grasp is strong on both hands. Strength of extremities are equally strong. There are no crepitations heard upon movement and deformities observed.

O. Reproductive System
Patient verbalized no swelling and tenderness on inguinal area. There are no unusual vaginal discharges noted.

P. Urinary System

Patient reported no pain upon urinating. Urine is amber yellow to dark yellow in color.

Q. Psychoemotional Aspect

Patient has a very supportive family and shows affection to the patient. She tends to be irritable and aloof at times and usually prefers to be alone. But she is open to discuss matters regarding her condition to her parents and siblings. She is a registered nurse who previously worked as a call center agent. Her mother verbalized that her friends are also very supportive and affectionate to her increasing the patient’s sense of self-esteem and positivity.
R. Spiritual
Patient attends masses every Sunday and during special occasions. She spontaneously prays every night before she sleeps and and every morning she wakes up. She alsoprays the rosary with her family.

Blood is a bodily fluid that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells. Blood is made up of liquid (called plasma) and solid cells. The bone marrow is the soft, spongy substance in the center of the bone where blood cells are made.

Fig.1 Bone Marrow

All our blood cells develop from stem cells. The process of blood cell development is called hematopoiesis. In the earliest stage of blood cell development, stem cells begin to develop either along the lymphoid cell line or the myeloid cell line. The blasts mature into 3 types of blood cells, called red bloods cells, platelets and white blood cells.

Fig.2 Development of Blood Cells

The main function of blood is to supply nutrients to and remove waste from cells, transport hormones to tissues and protect the body from harmful microorganisms. Each type of blood cell has a specific job.
Blood transports gases, namely oxygen (O2) and carbon dioxide (CO2), between the lungs and rest of the body, nutrients from the digestive tract and storage sites to the rest of the body, waste products to be detoxified or removed by the liver and kidneys, hormones from the glands in which they are produced to their target cells, heat to the skin so as to help regulate body temperature
Red blood cells carry oxygen from the lungs to the rest of the body and return carbon dioxide to the lungs. They are also called erythrocytes and they are the most common type of blood cell and the vertebrate organism’s principal means of delivering oxygen (O2) to the body tissues-via blood flow through the circulatory system. RBCs take up oxygen in the lungs or gills and release it into tissues while squeezing through the body’s capillaries.
Platelets also called “thrombocytes”, are blood cells whose function (along with the coagulation factors) is to stop bleeding. Platelets have no nucleus: they are fragments of cytoplasm which are derived from the megakaryocytes of the bone marrow, and then enter the circulation. These unactivated platelets are biconvex discoid structures shaped like a lens, 2-3 µm in greatest diameter. Platelets are found only in mammals, an adaptation that may have evolved to offset the risk of death from hemorrhage at childbirth – a risk unique to mammals.
White blood cells also called leukocytes or leucocytes, are the cells of the immune system that are involved in defending the body against both infectious disease and foreign invaders. Five different and diverse types of leukocytes exist, and several types (including monocytes and neutrophils) are phagocytic. All leukocytes are produced and derived from a multipotent cell in the bone marrow known as a hematopoietic stem cell. They live for about three to four days in the average human body. Leukocytes are found throughout the body, including the blood and lymphatic system.

Types of White Blood Cells
Granulocytes (from the myeloid cell line) are category of white blood cells characterized by the presence of granules in their cytoplasm. They are also called polymorphonuclear leukocytes (PMN, PML, orPMNL) because of the varying shapes of the nucleus, which is usually lobed into three segments. This distinguishes them from the mononuclear agranulocytes. In common parlance, the term polymorphonuclear leukocyte often refers specifically to neutrophil granulocytes the most abundant of the granulocytes; the other types (eosinophils, basophils, and mast cells) have lower numbers. Granulocytes are produced via granulopoiesis in the bone marrow. Granulocytes destroy bacteria to fight infection.
Neutrophils are formed from stem cells in the bone marrow. They are short-lived and highly motile. Neutrophils are a type of phagocyte and are normally found in the bloodstream. During the beginning (acute) phase of inflammation, particularly as a result of bacterial infection, environmental exposure, and some cancers, neutrophils are one of the first-responders of inflammatory cells to migrate towards the site of inflammation.
Eosinophils are white blood cells and one of the immune system components responsible for combating multicellular parasites and certain infections in vertebrates. Along with mast cells, they also control mechanisms associated with allergy and asthma. They are granulocytes that develop during hematopoiesis in the bone marrow before migrating into blood.
Basophils are the least common of the granulocytes, Basophils appear in many specific kinds of inflammatory reactions, particularly those that cause allergic symptoms. Basophils contain anticoagulant heparin, which prevents blood from clotting too quickly. They also contain the vasodilator histamine, which promotes blood flow to tissues. They can be found in unusually high numbers at sites of ectoparasite infection, e.g.,ticks.
Monocytes (from the myeloid cell line) are the largest of all leukocytes. Monocytes have bean-shaped nuclei that are unilobar, which makes them one of the types of mononuclear leukocytes (agranulocytes). They play multiple roles in immune function. Such roles include: (1) replenishing resident macrophages under normal states, and (2) in response to inflammation signals, monocytes can move quickly (approx. 8-12 hours) to sites of infection in the tissues and divide/differentiate into macrophages and dendritic cells to elicit an immune response. Half of them are stored in the spleen
Lymphocytes (from lymphoid cell line) are any of three types of white blood cell in a vertebrate’s immune system. All three are agranulocytes. They include natural killer cells (NK cells)), T cells (for cell-mediated, cytotoxic adaptive immunity), and B cells (for humoral, antibody-driven adaptive immunity). They are the main type of cell found in lymph, which prompted the name lymphocyte.The primary agents of the immune response are lymphocytes, white blood cells (leukocytes) that originate in the bone marrow (like all blood cells) but concentrate in lymphoid tissues such as the lymph nodes, the thymus gland, and the spleen.
B cells (B lymphocytes) can be distinguished from other lymphocytes, such as T cells and natural killer cells (NK cells), by the presence of a protein on the B cell’s outer surface known as a B cell receptor. This specialized receptor protein allows a B cell to bind to a specific antigen. The principal functions of B cells are to make antibodies against antigens, to perform the role of antigen-presenting cells (APCs), and to develop into memory B cells after activation by antigen interaction. B cells also release cytokines (proteins), which are used for signaling immune regulatory functions.
T cells are a type of lymphocyte (itself a type of white blood cell) that play a central role in cell-mediated immunity. They can be distinguished from other lymphocytes, such as B cells and natural killer cells (NK cells), by the presence of a T-cell receptor (TCR) on the cell surface. They are called T cells because they mature in the thymus (although some also mature in the tonsils)
Cytotoxic T cells (killer T cells) are activated when they recognize antigens that are mixed with the MHC-I proteins of self cells.
Helper T cells are activated when they recognize antigens that are mixed with the MHC-II proteins of self cells.
Suppressor T cells are believed to be involved in winding down a successful immune response and in preventing the attachment of uninfected self cells.
Memory T cells are long-lived cells possessing the same antigen receptors as their parent T cell.

The Lymphatic System
The Lymphatic System is part of the circulatory system, comprising a network of lymphatic vessels that carry a clear fluid called lymph directionally towards the heart. The other main function is that of defense in the immune system. Lymph is very similar to blood plasma but contains lymphocytes and other white blood cells. It also contains waste products and debris of cells together with bacteria and protein. Associated organs composed of lymphoid tissue are the sites of lymphocyte production.

The main function of the lymphatic system is to collect and transport tissue fluids from the intercellular spaces in all the tissues of the body, back to the veins in the blood system; it plays an important role in returning plasma proteins to the bloodstream; digested fats are absorbed and then transported from the villi in the small intestine to the bloodstream via the lacteals and lymph vessels. New lymphocytes are manufactured in the lymph nodes; antibodies and anti (manufactures in the lymph nodes) assist the body to build up an effective immunity to infectious diseases

Fig. 3 The Lymphatic System

Lymph is the fluid that circulates throughout the lymphatic system. The lymph is formed when the interstitial fluid (the fluid which lies in the interstices of all body tissues) is collected through lymph capillaries. It is then transported through lymph vessels to lymph nodes before emptying ultimately into the right or the left subclavian vein, where it mixes back with blood.
Lymph Nodes is an oval-shaped organ of the lymphatic system, distributed widely throughout the body including the armpit and stomach and linked by lymphatic vessels. Lymph nodes are major sites of B, T, and other immunity cells. Lymph nodes are important for the proper functioning of the immune system, acting as filters for foreign particles and cancer cells. Lymph nodes do not deal with toxicity, which is primarily done by the liver and kidneys.

Major Accessory Lymphatic Organs
The tonsils (palatine tonsils) are a pair of soft tissue masses located at the rear of the throat (pharynx). Each tonsil is composed of tissue similar to lymph nodes, covered by pink mucosa (like on the adjacent mouth lining. The tonsils are part of the lymphatic system, which helps to fight infections.
The spleen is the largest lymphatic organ. It is located in the upper-left abdomen. The spleen:makes, stores and removes lymphocytes, filters the blood, stores red blood cells, destroys old red blood cells
The thymus gland, despite containing glandular tissue and producing several hormones, is much more closely associated with the immune system than with the endocrine system. The thymus serves a vital role in the training and development of T-lymphocytes or T cells, an extremely important type of white blood cell. T cells defend the body from potentially deadly pathogens such as bacteria, viruses, and fungi. The thymus is a soft, roughly triangular organ located in the mediastinum of the thoracic cavity anterior and superior to the heart and posterior to the sternum.
The adenoids are actually a single, small mass of lymphatic tissue in the back of the nose (nasopharynx) that contains lymphocytes. Although they are often called adenoids there is only one adenoid. The adenoid is also sometimes called the pharyngeal tonsil.
Bone marrow
The bone marrow is a flexible tissue in the interior of bones. In humans, red blood cells are produced by cores of bone marrow in the heads of long bones in a process known as hematopoiesis. It is also a key component of the lymphatic system, producing the lymphocytes that support the body’s immune system.

The Pleura are double-layered serous membranes that surround each lung. Attached to the wall of the thoracic cavity, parietal pleura lines the thoracic wall, covers the superior surface of the diaphragm and separates the pleural cavity from the mediastinum. The costal portion of the parietal pleura lines the inner aspect of the ribs and intervening intercostal muscles, being separated from them by endothoracic fascia. The visceral pleura is attached directly to the lungs, as opposed to the parietal pleura, which is attached to the opposing thoracic cavity. The space between these two delicate membranes is known as the intrapleural space (pleural cavity). Contraction of the diaphragm causes a negative pressure within this space and forces the lungs to expand, resulting in passive exhalation and active inhalation

Pleural Cavity is between the parietal and visceral pleura which creates a hollow space for the lungs to expand into during inhalation. Serous fluid secreted by the pleural membranes lubricates the inside of the pleural cavity to prevent irritation to the lungs during breathing.

Diaphram is the dome-shaped sheet of muscle and tendon that serves as the main muscle of respiration and plays a vital role in the breathing process. Also known as the thoracic diaphragm, it serves as an important anatomical landmark that separates the thorax, or chest, from the abdomen. The origins of the diaphragm are found along the lumbar vertebrae of the spine and the inferior border of the ribs and sternum. Openings in the diaphragm allow the esophagus, phrenic and vagus nerves, descending aorta, and inferior vena cava to pass between the thoracic and abdominal cavities.
Bronchioles are made of elastin fibers and smooth muscle tissue. The tissue of the bronchiole walls allows the diameter of bronchioles to change to a significant degree. When the body requires greater volumes of air entering the lungs, such as during exercise, the bronchioles dilate to permit greater airflow. In response to dust or other environmental pollutants, the bronchioles can constrict to prevent the pollution of the lungs.
Alveoli, found in the lung parenchyma, the pulmonary alveoli are the terminal ends of the respiratory tree, which outcrop from either alveolar sacs or alveolar ducts, which are both sites of gas exchange with the blood as well. Alveoli are the functional units of the lungs that permit gas exchange between the air in the lungs and the blood in the capillaries of the lungs. Each alveolus is a hollow, cup-shaped cavity surrounded by many tiny capillaries.


Fig.4 Gastrointestinal System
Esophagus is one of the upper parts of the gastrointestinal system. At the mouth opening, it is continuous with the back of the oral cavity, passing downwards through the rear part of the mediastinum , through the diaphragm, and into the stomach.
Lower Esophageal Sphincter (LES) is a bundle of muscles at the low end of the esophagus, where it meets the stomach. When the LES is closed, it prevents acid and stomach contents from traveling backwards from the stomach. The LES muscles are not under voluntary control.

Handling different cases helped us to have an idea on what will be our priority care and at the same time, differentiate what nursing care will be done to a specific case. We have chosen Acute Lymphocytic Leukemia (ALL) because an increasing attention has been paid to patients who were diagnosed with this case. ALL is a disease that may occur at any stages of one’s life but, it is the most common type of leukemia in children and young adults younger than 20 years. Patients with ALL need supportive care physically, emotionally, spiritually and psychologically.
Acute lymphocytic leukemia (ALL) is a type of cancer of the blood and bone marrow – the spongy tissue inside bones where blood cells are made.The word “acute” in acute lymphocytic leukemia comes from the fact that the disease progresses rapidly and creates immature blood cells, rather than mature ones. The “lymphocytic” in acute lymphocytic leukemia refers to the white blood cells called lymphocytes, which ALL affects. Acute lymphocytic leukemia is also known as acute lymphoblastic leukemia.
ALL is divided into two major subtypes based on the physical characteristics and the level of development of the leukemia cells. This basic classification helps the treatment team to start planning the best course of treatment for the patient. The principal ALL subtypes are B-cell acute lymphocytic leukemia and T-cell acute lymphocytic leukemia.
T-cell acute lymphocytic leukemias is a rare type of leukemia. There are no specific symptoms of T-cell acute lymphocytic leukemia and the condition can be focused with other common illnesses. In general, T-cell acute lymphocytic leukemia develops very quickly and the symptoms appear over a matter of days or weeks. It is also not an inherited condition that can be passed down through families.
The American Cancer Society’s estimates for acute lymphocytic leukemia (ALL) in the United States for 2014 (including both children and adults) are:
• About 6,020 new cases of ALL (3,140 in males and 2,880 in females)
• About 1,440 deaths from ALL (810 in males and 630 in females)
The average person’s lifetime risk of getting ALL is less than 1 in 750. The risk is slightly higher in males than in females, and higher in whites than in African Americans.
Most cases of ALL occur in children, but most deaths from ALL (about 4 out of 5) occur in adults. Children may do better because of differences in childhood and adult ALL in the disease itself, differences in treatment (children’s bodies can often handle aggressive treatment better than adult’s), or some combination of these.
The Philippine Cancer Society, Inc. 2010 published a study about the different types of cancer in the Philippines. Leukemia was one of the top 10 cancer cases of both sexes with estimated total of 3153 new cases. There were 1484 estimated new cases of leukemia that ranked as 8th leading cause of morbidity among women and estimated cancer deaths of 1228 in the Philippines that ranked 6th among the top 10 mortality rates.

Upon completion of this case study, the nurses will be able to:
* Identify causative factors of the occurrence of the disease
* Explain the pathophysiology of the client’s condition
* Formulate significant nursing diagnoses with the appropriate nursing care plans regarding the disease and its complications
* Utilize two nursing theories fit to the case of the patient unto the said nursing care plans
* Apply effective nursing interventions that will be proven useful for the client
* Know the medical and surgical management of this specific case

Upon the completion of this case study, client will be able to:
* Understand the disease process
* Know the different medical regimen and their purposes
* Demonstrate willingness in coordination with healthcare maintenance
* Learn how to prevent complications of the disease through life style modifications and diligently complying to medication and therapy regimen.

Treatment of patients with acute lymphocytic leukemia depends on age of patient. In general, treatment falls into two phases:

• Remission induction therapy. The purpose of the first phase of treatment is to kill the leukemia cells in the blood and bone marrow. However, remission induction usually doesn’t wipe out all of the leukemia cells, so one needs further treatment to prevent the disease from returning.

• Consolidation therapy. Also called post-remission therapy, maintenance therapy or intensification, this phase of treatment is aimed at destroying the remaining leukemia cells. It’s considered crucial to decreasing the risk of relapse.

Therapies used in these phases include:

• Chemotherapy. Chemotherapy is the major form of remission induction therapy. A common course of therapy involves two chemotherapy drugs – cytarabine (Cytosar-U), followed by an anthracycline drug, such as daunorubicin (Cerubidine) or idarubicin (Idamycin). A third medication, thioguanine, is sometimes used. This chemotherapy can cause anemia, infection and bleeding. If the first cycle of treatment doesn’t cause remission, one may need it repeated one or two more times.

Other drug combinations also may be used, depending on the specific situation.

Chemotherapy can also be used for consolidation therapy. This phase may include a combination of different medications that mimic the induction, but usually includes high doses of cytarabine by itself for one to three cycles. The doctor may also prescribe medications that boost white cell production to reduce the risk of infection. These medications are called granulocyte colony stimulating factors (Neupogen, Leukine).

• Other drug therapy. Arsenic trioxide and all-trans retinoic acid (ATRA) are anti-cancer drugs that can be used alone – or in combination with chemotherapy – for remission induction of certain leukemias. These drugs cause leukemia cells with a specific gene mutation to mature and die, or to stop dividing.

• Biological therapy. Also known as immunotherapy, biological therapy uses substances that bolster the immune system’s response to cancer.

Monoclonal antibodies are one form of biological therapy. These antibodies are produced in a laboratory, but they mimic protein products found in the immune system (antibodies) that attack foreign substances (antigens) on leukemic cells.

• Bone marrow transplant. This is another option for consolidation therapy for people at high risk of relapse or for treating relapse when it occurs. This procedure allows someone with leukemia to re-establish healthy stem cells by replacing their leukemic bone marrow with leukemia-free marrow. If one chooses this treatment, he’ll receive very high doses of chemotherapy or radiation therapy to destroy his leukemia-producing bone marrow. This marrow is then replaced by bone marrow from a compatible donor (allogeneic transplant). In some cases, he may also be able to use his own bone marrow for transplant (autologous transplant). This is possible if he goes into remission and then save healthy bone marrow for a future transplant.

• Stem cell transplant. Stem cell transplant is also used for consolidation therapy. It’s similar to bone marrow transplant except the stem cells are collected from circulating blood (peripheral blood), rather than from the bone marrow, thanks to a medication that causes larger numbers of stem cells to be released from the bone marrow. The cells used for transplant can be his own healthy cells, or they can be collected from a compatible donor.

This procedure is used more frequently than bone marrow transplant because of shortened recovery times and possible decreased risk of leukemia recurrence.

• Radiation Therapy. Radiation therapy involves the use of radiation to kill cancer cells and shrink tumors. In external radiation therapy, radiation is directed at the tumor from a source outside the body. This type of treatment is used for ALL has spread-or may spread-to the brain and spinal cord. It can also be used to treat bone pain that comes from bone affected by the leukemia.

The patient underwent radiation therapy for her mediastinal lymphoma and seven cycles of chemotherapy since February 2014 until now. Chemotherapeutic drugs used were Lanase, Vincristine and Cytarabine. She also had blood transfusions of five units of packed red blood cells and four units of apheresis platelet concentrates. Apheresis platelets are collected from a single donor and are equivalent to ~4-6 pooled units. An apheresis platelet concentrate contains 200-400mL of plasma. They may be collected as a random unit (random apheresis platelets) or be obtained for a specific recipient from a family member or a volunteer HLA compatible “directed” donor.
While admitted, IV fluid insertion was done as means for her medications. Upon assessment, she had a plain normal saline solution infusing well at her right metacarpal vein with a prescribed flow rate of 20 gtts/min.