careplan 1-dh

8/6/2019 Careplan 1-DH

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DW is a 74 year old patient who prior to this diagnosis was in good health , current HX of HTN

with previous HX of Cholecystectomy 5 years ago, carpal tunnel surgery 3 years ago and cataract

surgery in past year. No HX of smoking, occasional social alcohol use noted. Family HX of CA with

patients mother being TX for both lung and bowel CA , mother lived until she was 92 years of age. PT

was definitively DX with AML (acute myelogenous leukemia) on October 15 2009 via results of bonemarrow aspiration report; testing was done in response to PT attempting to get pain injection for back

pain (unspecified source) Dr wanted an MRI done prior to TX, did not like the way the bones appeared

(per patient) on MRI scan and ordered additional blood work, upon results preliminary DX was made

and PT was referred to primary care physician for further evaluation. This admit on October 28, 2009 is

for induction treatment of Chemotherapy, patient was under my care during the second 24 hours of his

admit, on day one the patient had a PICC (peripheral inserted central venous catheter) inserted in his

upper right arm to serve as a route for administration of his chemotherapy treatment. During induction

he was being treated with 2 chemotherapy agents; Idarubicin (idamycin) 12mg/m2/QD given as 24mg

slow injection over 15 minutes QD and Cytarabine 195mg in 1000 NS administered at 41.75ml per

hour for 24 hours. As this was very early in the induction phase he was asymptomatic from both the

chemotherapy and the disease process itself. Physical exam was unremarkable with no complaints of

pain or nausea noted.

Leukemia is a form of cancer characterized by the uncontrolled production of immature white

blood cells in the bone marrow. This process results in the replacement of healthy normal blood cells

by the immature nonfunctional WBC's, due to the rapid proliferation of these cells production of

normal cells is greatly decreased. Classification of Leukemia is done according the cell type that is

proliferating. AML presents as neoplastic growth of cells from the myeloid, monocytic, erythrocytic or

megakaryotic precursors. Etiology of the disease is defined as aberrations in both genetic and

chromosomal markers. Acute myelogenous leukemia is the most common form of adult leukemia;

exact cause is unknown, even with aggressive treatment average survival time is only approximately

one year after diagnosis.

AML is treated in 2 separate phases versus the 3 phases used for ALL; these stages are

induction with cytarabine and an anthracycline (antibiotic based drugs that block DNA synthesis in

neoplasms) and then post remission intensification, maintenance chemotherapy or bone marrow

transplantation. The goal of this approach to therapy is to achieve a rapid, complete resolution of all

manifestations of the disease. Prophylactic use of antibacterial, antiviral and anti fungal agents is

common to prevent complications from secondary infections related to the suppression/decrease

function of the immune system.


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Leukemia Risk Factors

Textbook (Iggy, pg 898) Patient reported

Exposure to ionizing radiation; either previous

cancer tx or environmental

N/A

Previous exposure to chemicals and drugs used in

cancer treatment

N/A

Bone marrow hypoplasia N/A

Genetic factors associated with down syndrome,

Bloom syndrome, Klinefelter syndrome orFanconi's anemia

N/A

Interaction of multiple host and environmental

factors (nonspecific)

N/A

Signs and Symptoms

Textbook (Iggy, pg 898) Patient reported

Easy bruising or bleeding (r/t low platelet count) N/A

Paleness/fatigue N/A

Recurrent minor infections N/A

Slow/poor healing of minor cuts abrasions N/A

Diagnosis/Treatment

Patient diagnosis was done per textbook standard, bone marrow aspiration testing is the

definitive test done for confirmation of a Leukemia diagnosis; his initial referral for bloodwork was not

standard as it stemmed from an attempt to get an injection for back pain. Patient treatment at this point

appears to be following the standard regimen used for AML, my patient is currently undergoing

induction phase and it is assumed that this will then be followed up with the post-remission phase of

chemotherapy treatment.


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Medications

Medication Reference page # Action Reason used

Dexamethasone 20mg +

50 ML NS

331 Nursing Spectrum

Drug Handbook

(N.S.D.H.)

Synthetic corticosteroid

works as an anti-

inflammatory agent

Prophylactic use to

offset irritation caused

by chemotherapy agents

Idarubicin 23 mg(Idamycin PFS)

570 (N.S.D.H.) Inhibits DNA/RNAsynthesis of tumor

Causes cell death ofneoplastic cells

(antineoplastic)

Lansoprazole 30mg

(Prevacid)

637 (N.S.D.H.) Inhibits proton pump in

parietal cells, reducing

gastric acid production

Prophylactic use to

decrease chance of ulcer

formation/esophagitis common s/e of

chemotherapy

Metoclopramide 10mg

(Reglan)

746 (N.S.D.H.) Blocks dopamine

receptors in the CNSCTZ zone

Prevent chemotherapy

induced vomiting

Multivitamin withminerals

Supplements dietaryintake, without intake of

additonal food

Use is prophylactic tosupplement dietary

requirements

NS 1000 ml +

cytarabine 195mg

297 (N.S.D.H.) Unclear, cytotoxic effect

may stem from

inhibition of DNA bydrug's active metabolite

Causes cell death of

neoplastic cells

(antineoplastic)

Nifedipine 90mg

(Procardia XL)

822 (N.S.D.H) Calcium channel

blocker

Hx htn, suppresses

smooth and vascular

muscle contraction


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10/29/2009 Diagnostics Value Nrml Significance

WBC 42.2 4 - 11 Proliferation of WBC is

at this point uncheckedby the chemotherapy

RBC 2.68 3.7 5.4 Decrease in RBC due to

overproduction of WBCdue to AML

HGB 8.9 11.4 15.4 Decrease in HGB can

occur with chronicillness due to disease

process itself or

nutritional deficiencies

from disease ortreatment

Hct 27.7 35 - 47 Decrease in HCB can

occur with chronic

illness due to diseaseprocess itself or

nutritional deficiencies

from disease or

treatment

Plt 41 150 - 400 Suppressed from diseaseprocess and side effect

of cytotoxic

chemotherapy drugregimen

Glucose 140 70 - 110 Elevated from stressreaction to

environmental change

and administration ofdexamethasone adjunct

Bone marrow aspiration report on October 15 th, 2009.

Definitive DX of Acute Myelogenous Leukemia with leukocytosis; severe macrocytic anemia and

moderate/severe thrombocytopenia.


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Nursing Diagnosis #2

Fatigue r/t to chemotherapy treatment and decreased tissue oxygenation AEB decreased RBC 2.68 (3.7-

5.4 nrml), HGB 8.9 (11.4 15.4 nrml) and HCT 27.7 (35 47 nrml).

GoalPatient will not exhibit or verbalize additional feelings/signs of fatigue while in my care.

Interventions Rationales

Provide adequate nutrition to the patient and

monitor how much is consumed. If inadequateconsider either nutritional supplement or possible

refer to dietary for consult

Adequate balanced intake is key to maintaining

energy and meeting metabolic needs. Supplementis a good concentrated source of nutrition. Dietary

consult would be to offer alternative nutritional

sources or delivery forms.

Ensure adequate fluid intake via oral and monitorIV flow as ordered; decreases risk of dehydrationand altered fluid imbalance

Dehydration /fluid imbalance exacerbate increaseof fatigue and lethargy

Encourage adequate rest. Proper amount of rest conserves energy and

decreases feelings of fatigue.

Give metoclopramide (Reglan) 10mg IVP, as

needed to decrease nausea/vomiting

Nausea decreases desire to eat, vomiting puts

patient at greater risk for dehydration.

Give multivitamin with minerals as prescribed Dietary supplement to address any deficiencies

that are not covered by dietary intake.

Evaluation:

Patient ate 100% of breakfast x2, and 100% of lunch. Fresh water was offered and consumed x 2. NS

ran at 100ml per hour along with NS + cytarabine at 41.54ml per hour. Patient walked floor circuit

three loops, took shower, and was up in chair visiting family during my care. Patient showed no sign of

fatigue and reported no signs of fatigue, compared to previous day.


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Nursing Diagnosis #3

Risk for impaired oral mucosa r/t side effects of chemotherapy regimen

Goal

Patient will not exhibit Si/Sx of stomatitis, an inflammation of the oral mucous membranes that is aside effect of chemotherapy/

Interventions Rationales

Inspect the oral cavity per shift at minimum Assess for any changes in baseline, discolorations,

bleeding or discolorations, could be signs ofstomatitis

Promote use of soft bristle toothbrush and to avoid

brushing too hard

Soft bristle toothbrush and soft deliberate

brushing will help maintain the integrity of the

oral mucosa.

Encourage the patient to brush his tongue with the

toothbrush when doing oral care.

Can increase taste sensation, and decrease

bacterial count in oral cavity.

Encourage frequent oral fluid intake. Water ispreferred

Maintaining moisture in mouth can decreaseincidence of stomatitis

Encourage care in selection of foods that are

eaten, avoid high salt foods (chips), softer foods

that are easier to chew preferred

High salt leads to drying of oral cavity, chips can

abrade skin and alter integrity.

Evaluation:

Oral cavity was inspected and no problems found. No lesions, bleeding, discoloration noted. Soft

toothbrush was used, frequent water intake and swish was done. Foods were soft and easily chewed.


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What I learned from this patient:

I really enjoyed taking care of DW on my first clinical day. We bonded well and I was able to

establish a strong rapport in fairly short order. Pt is a 74 yo male in excellent physical health, outside of

the current disease process his only other medical complaint is hypertension. He seemed to be handlinghis current diagnosis in stride, he was not particularly happy with how long he was going to be

hospitalized for treatment but was optimistic regarding the outcome of the treatment, at this point he

seems to be coping very well, as is his wife and daughter.

I learned that I need to become more systematic in my acquisition of information from the

computerized chart, much harder to scan the chart and catch abnormal values, etc. I am hoping that

will come with time on the system. I suppose the biggest thing I learned from my patient is how

important it is have a positive attitude and I know from my personal experience what an impact that can

have on the treatment outcome. I would like to check in on him during his hospitalization to see how he

is doing as the treatment progresses if that would be appropriate.


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References

Ignatavicius, D.D., Workman, M.L. (2006) Medical -Surgical Nursing: Critical thinking for

collaborative care. St Louis, MO: Elsevier Saunders.

Schilling, J.A., (2007) Lippincott manual of nursing practice series: Pathophysiology. Philadelphia,

PA: Lippincot Williams & WilkinsSchull, P.D., (2010) Nursing spectrum drug handbook. New York, NY: McGraw-Hill.

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