1
Acute Lymphoblastic Leukemia (ALL) SKINNY
Reasoning
April Peters, 10 years old
Primary Concept
Cellular Regulation
Interrelated Concepts (In order
... [Show More] of emphasis)
Infection
Perfusion
Clinical Judgment
Patient Education
NCLEX Client Need Categories Percentage of Items from
EachCategory /Subcategory
Covered in
Case Study
Safe and Effective Care Environment
Management of Care 17-23%
Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12%
Basic Care and Comfort 6-12%
Pharmacological and Parenteral Therapies 12-18%
Reduction of Risk Potential 9-15%
Physiological Ada tation 11-17%23
Part 1: Recognizing RELEVANT Clinical Data
History of Present Problem:
April Peters is a 10-year-old female with acute lymphoblastic leukemia (ALL) who presents to the emergency department
with a temperature of 38.4 degrees C. (101.2 F.) and a complaint of a sore throat. She has been receiving
chemotherapy since her diagnosis three months ago. April's mother reports that her fever has been unresponsive
to acetaminophen and she is two days out from her most recent chemotherapy treatment. No reports of nausea,
vomiting, or diarrhea noted. A CBC is drawn immediately from April's central venous access device (CVAD) and
April is admitted directly to the pediatric oncology unit where you are the nurse responsible for her care. She
weighs 57 lbs. (25.9 kg), is 51.5 inches (128.8 cm.) and has NKDA.
Personal/Social History:
April lives at home with her mother Cindy, her father Tom, and her 6-year-old sister Maggie. Tom works fulltime as an engineer while Cindy stays home with the children because of April's diagnosis and resulting
hospitalizations and treatment. April has missed quite a few days of school. Although her school system has
provided April with a tutor to keep up with her studies, April does not return telephone calls from her friends
and refuses their visits.
Past Medical History (PMH):
o Cindy's pregnancy was uneventful and April was born via an uncomplicated vaginal delivery at 40
weeks and weighed 7 lbs., loz. (3.2 kg.)
o Tonsillectomy at 3 years old under general anesthesia.
o ALL diagnosis 3 month ago following a short history of headaches and pallor. April's WBC count at
diagnosis was 469,000 FYI: Hyperleukocytosis is defined as a peripheral white blood cell count greater
than 100,000/mm3 and is a pediatric oncologic emergency. These white blood cells are immature blast
cells not normal cells. Hyperleukocytosis can progress to capillary obstruction, microinfarction, and
organ dysfunction, which can lead to respiratory distress and cyanosis. Children may also experience
changes in neurologic function, including an altered level of consciousness, visual disturbances,
confusion, and ataxia.
What data from the histories is RELEVANT and has clinical significance to the nurse?
RELEVANT Data from Present
Problem:
Clinical Significance:
10-year-old female with acute
lymphoblastic leukemia (ALL)
She has been receiving
chemotherapy since her diagnosis
three months ago.
She is two days out from her most
recent chemotherapy treatment.
It is important to know that the patient is 10 years old to adapt the
plan of care to her stage of development. Knowing her cancer
diagnosis of ALL is key to understanding that she is presenting as an
emergent case and what nursing interventions are critical for a patient
with ALL. Knowing she was only diagnosed 3 months ago is very
important to note as she has not dealt with the disease very long, is
currently undergoing chemotherapy and had her last treatment two
days ago. This information can provide insight to what is causing her
symptoms and what diagnostic testing should be done. Also, it tells us
she is actively fighting the cancer and is not in remission, thus
making her immunocompromised and susceptible to infections. ALL
is characterized by cancerous cells in the bone marrow producing
excessive amounts of immature white blood cells that can lead to
damage in the circulatory system and in the organs of the body if
levels are too high. Chemotherapy is used because it destroys the
cancerous tissue. Unfortunately, it also affects healthy tissues/cells
and reduces the white blood cell count, cancerous and healthy, until
the immune system is no longer able to function efficiently to be able
to fight off foreign bacteria and invading viruses.
Temperature of 38.4 degrees C.
(101.2 F.) and a complaint of a sore
A temperature over 100.4 in pediatric patients with cancer is
considered an emergency! Fever and sore throat are signs of4
throat. April's mother reports that
her fever has been unresponsive to
acetaminophen and no reports of
nausea, vomiting, or diarrhea noted.
A CBC is drawn immediately from
April's central venous access device
(CVAD) and April is admitted
directly to the pediatric oncology
unit
infection, reactions/side effects to chemotherapy. Chemotherapy often
causes pain and irritation of various tissues, it causes patients to feel
fatigue and malaise.
An unresponsive fever despite interventions requires immediate
intervention
Knowing if the patient is experiencing nausea etc. is important to help
the healthcare team distinguish the possible cause of the patient’s
symptoms.
Since ALL occurs with too many immature WBCs and lifethreatening complications can occur, it is important to draw labs
immediately and admit the patient. CBC, liver panels and other labs
will give insight to her immune status, if she requires neutropenic
precautions, if any of her organs are being affected by her
chemotherapy and for signs of possible sepsis or cancer
complications.
Her CVAD will be used to reduce any new portals of infection and
for efficiency as patients veins are difficult to start IVs with as their
veins
RELEVANT Data from Social
History
Clinical Significance:
April has missed quite a few days
of school. Although her school
system has provided April with a
tutor to keep up with her studies,
April does not return telephone
calls from her friends and refuses
their visits
57 lbs. (25.9 kg), is 51.5 inches
(128.8 cm.) and has NKDA.
Difficulty keeping up with school and not wanting to speak and see
friends could indicate that April is struggling to adjust to her
diagnosis and the symptoms that come along with ALL. Also, the side
effects of chemo drugs likely affect her self esteem and she may feel
depressed. Being around other children is very important for a child’s
development socially and developmentally as their interaction with
others allows them to learn more about interactions and how the
world works. Without it, it places her at risk for delayed social
development that will leave her possibly struggling with identifying
and communicating with others now and in the future.
Knowing her height and weight is important to calculate safe dosages
of her medications as well as knowing if she has any allergies.
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 100.8 F/38.2 C (oral) Provoking/Palliative
:
"My throat hurts"
P: 112 (reg) Quality: "Bad"
R: 24 (reg) Region/Radiation: Throat
BP: 102/66 Severity: "I don't know."
02 sat: 96% on room air Timing: Ongoing5
What VS data are RELEVANT that must be recognized as clinical significance by the nurse?
RELEVANT VS Data: Clinical Significance:
T: 100.8 F/38.2 C (oral)
P: 112 (reg)
R: 24 (reg)
"My throat hurts" “Bad”
Throat “I don’t know”
ongoing
Fever over 100.4 is dangerous, it is also a sign of infection/immune
response. Fever is also a symptom of ALL and further diagnostic testing
would be required to determine if the fever is occurring due to an
infection or as a result of the cancer.
Pulse is elevated, could accompany fever. The patient is likely afraid, they
feel ill and they have just been diagnosed with cancer and began
undergoing chemotherapy. Chemotherapy suppresses all functions of the
body and the production of WBCs and RBCs which affects both the
immune system and the circulatory system. Anemia is a condition with
less RBCs meaning that the body has less healthy hemoglobin to carry
adequate oxygen to the body which would lead to an increased pulse and
respiratory rate to compensate for the oxygen demands.
Elevated RR corresponds with the tachycardia. Could be related to the
fever or the patient’s possible anemia that is secondary to her cancer
treatment suppressing her RBC production. Less oxygen carrying
capacity would cause the body to compensate by moving the blood
through the circulatory system faster to pick up oxygen and move it
throughout the body fast enough to meet the demand.
The source of pain in the throat could indicate an infection, specifically a
strep throat infection that is common among children. It is caused by the
Streptococcus genus and is characterized by white exudate on the tonsils,
mouth and throat. It is very painful and lymph nodes are commonly sore
and swollen. It could have been an infection that could possibly have
developed into a systemic bacterial infection. Possibly, she could have
developed mucositis which is common with chemotherapy and occurs
when tissue becomes inflamed and irritated and it may have become a
portal of entry for the infection to take root and become strep throat,
before entering the bloodstream.
Likely is not suffering from decreased oxygen levels or any oxygen issues
at this point in time. However, at 10 years old with no other respiratory
issues she should have a O2 saturation near 100%. Having oxygenation at
the lower end could be related to anemia secondary to her chemotherapy
treatment.6
O2 96% RA
All of these VS data indicates an infection supported by pain in the throat.
These are all significant findings for a patient with leukemia because classic signs of infection may
be absent due to bone marrow suppression and infection is a major concern for a child receiving
treatment for cancer.7
Current Assessment:
GENERAL APPEARANCE: Resting in bed with eyes closed, pale in appearance.
RESP: Breath sounds clear with equal aeration bilaterally, unlabored
respiratory effort
CARDIAC: Skin is pale, cool to touch. Cap. Refill 3-4 seconds in both hands. No
edema noted, heart sounds regular with no abnormal beats, radial and
pedal pulses present and strong.
NEURO: Patient appears lethargic, drowsy, oriented x4.
GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all
four quadrants. Last BM yesterday evening
GU: Voiding without difficulty
SKIN Skin integrity intact. Central venous access device (CVAD) in place,
dressing intact
What assessment data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data: Clinical Significance:
Resting in bed with eyes closed, pale
in appearance.
Resp is within normal limits
Skin is pale, cool to touch. Cap. refill
3-4 seconds in both hands.
The patient is presenting as very ill, likely feels malaise and has
developed a serious condition (infection most likely). Also, with
severe anemia patients feel lethargic and become pale due to the
lack of oxygen being circulated through the body and the elevated
pulse and respiratory rate use more energy to help compensate for
the lack of oxygen carrying capacity.
The patient is not experiencing anything major affecting her
oxygenation ability in her respiratory system, mechanically.
However, if her oxygen carrying capacity is low her respiratory
system will begin to compensate if the underlying cause is not
treated (anemia).
The paleness is likely due to two factors. One is anemia which
causes a reduction of the red appearance in the skin due to low
numbers of RBC in the blood. Second is that paleness is an indicator
of poor circulation. The coolness of the patient’s skin indicates poor
circulation also and possibly chills as the patient has a fever. The
extended capillary refill is very alarming and may indicate a serious
illness (sepsis etc) and/or dehydration. Dehydration would occur
quickly in a child who is immunocompromised and fighting a severe
infection.
Signifies the severity of the patient’s condition. A 10 year old should
be up and alert. She has undergone draining chemotherapy
treatments and has now developed a serious infection that her body
is too weak to fight off, wreaking havoc on any energy stores and
immune system. Anemia caused by her chemotherapy could also
contribute to feeling lethargic as her body has to compensate
(PR/RR) to meet the body’s oxygen requirements.
A patient who is immunocompromised and ill should immediately
be placed on neutropenic precautions. CVAD allows for convenient
access for patients undergoing chemotherapy. However, they could
also be portals of infection and the patient should only have I.V.
access through this port to limit instances that may introduce8
lethargic, drowsy,
Central venous access device
(CVAD) in place, dressing intact
GU: urinating without difficulty
bacteria. Especially when infection is suspected. It is important to
assess the CVAD portal site routinely with blood cultures because it
can get infected if not cared for properly. A pt with ALL with any
type of portal access is especially at high risk for infection and an
immunocompromised patient will poorly tolerate even a minor
infection.
A full GU assessment should be conducted, evaluating when her last
void was, what the color, clarity and diagnostic levels did it have? It
could indicate if she could possibly have a UTI as the source of her
infection? Her age group is predisposed to UTIs as they may have
poor elimination habits and she is more susceptible to infections as
she is immunocompromised and is a female.
Diagnostic Results:
BMP
Na K Gluc. Creat.
Current 130 3.5 70 1.4
Most Recent 129 3.3 82 1.1
CBC
WBC HGB PLTs % Neuts Bands
Current 0.2 7.4 54 1 0
Most Recent 0.36 8.2 61 0 0
Liver panel
Albumin Total Bili Alk. Phos. ALT AST
Current 3.5 1.0 75 42 49
Most Recent 3.9 0.9 79 20 21
MISC
Lactate Ionized Ca Mg Amylase Lipase
Current 1.8 I .05 1.9 29 31
Recent 1.7 1.11 2.0 31 399
What data must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic
Adaptation)
Relevant Data: Clinical Significance
TREND:
Improve/Worsenin
g /Stable:
Cr
1.4
Normal: 0.5 – 1.0 mg/dL for 10 years old
Elevated levels are likely due to the pt’s recent
chemotherapy treatment as it is harmful to all tissues and
would affect the kidneys ability to function normally.
Also, dehydration leads to higher levels.
Worsening
WBC
0.2
Normal: 5,000-10,000 /mm^3
Critically low is below 2,000. This is a significant drop
from 3 months ago. Although a lower value is expected
in her condition due to chemotherapy treatment and
ALL, this is extremely low and makes the patient
immunocompromised as her WBC level is too low for
her immune system to function properly against any
illnesses/infections.
Worsening.
AST
49
Normal AST value is 10-15 unit/L. Elevation in AST can
be due to the recent chemotherapy treatment or can be an
indicator for liver damage as it is released when the cells
are damaged by the chemotherapy.
Worsening
ALT
42
Normal: 4-36 units/L. Elevated. Chemotherapy can
induce abnormalities of the liver function as it damages
healthy cells leading to the release of alt. Her bili levels
are still within the normal range, although on the higher
end. This may be an indicator of liver dysfunction
related to her chemotherapy treatment.
Worsening
PLT
54
Normal: 150,000-400,000/mm^3.Extremely low, likely
due to chemo treatment. Cytotoxic drugs often affect
the bone marrow and platelets are not produced at
adequate levels. This is important because platelet
activity is essential to blood clotting and puts the patient
at risk for prolonged bleeding.
Worsening
Albumin
3.5
Normal: 4-5.9 g/dL. Slightly low. This indicates a
protein abnormality that is typically seen in hematologic
malignancy. This may also be an indicator of inadequate
production by the liver, especially combined with
elevated liver enzymes. This would indicate a delay in
RBC production that is related to anemia, which would
account for the patient’s symptoms of increased
PR/RR/paleness/Lethargy.
Worsening
HGB
7.4
Normal hemoglobin count for a 10 y/o is 10-15.5 g/dL.
critically low is below 7 and she is near requiring a
blood transfusion. Decreased levels of hemoglobin is
expected in patients with ALL but a decreasing trend is
an indicator of a worsening condition. Low hemoglobin
Worsening10
count can affect her respiratory functions as it attempts
to compensate for low oxygen capacity. This correlates
to anemia and the suppressed production of RBCs.
Neutrophils
1%
Normal: 55-70%, without adequate white blood cells the
body is ill equipped to fight off infections. Neutrophils
are especially important for acute bacterial infections.
healthy wbcs are made with functioning bone marrow, if
this process is suppressed as it is with chemotherapy
then the body will not have a functioning immune
system.
worsening11
Part II Put it All Together to THINK Like a Nurse!
1. After interpreting relevant clinical data, what is the primary problem? (Management of Care/Physiological
Adaptation)
Problem: Pathophysiology in OWN Words:
Infection/neutr
openia/anemia
related to
chemotherapy
Chemotherapy is used to treat cancer. As it destroys cancerous cells it also affects healthy
cells which leads to suppression of various functions of the body. WBC and RBC
production is suppressed, leading to neutropenia and anemia where there are not enough
mature, healthy WBCs to fight off infections and low RBC levels that impact the body’s
ability to meet its oxygen demands. Neutropenia is very common with chemotherapy
treatment and strict precautions of washing hands, wearing face masks and limiting contact
with others to avoid contracting any illnesses as her low WBC count leaves patients very
vulnerable as their immune system is not effective against any sort of infection. While the
body is trying to fight off the infection despite not having a functioning immune system,
the body uses up more oxygen and energy to do so. This stresses the body’s oxygen
carrying capacity is suppressed with less RBCs and hemoglobin production to circulate
enough oxygen to meet demands.
Strong antibiotic treatment and strict monitoring of her vitals, I & Os, CBC and lab data
and monitoring her infection status to help her fight off the infection. Until the infection is
treated the body will continue to employ compensatory measures.
Collaborative Care: Medical Management
2. State the rationale and expected outcomes or the medical plan of care. (Pharm. and Parenteral Therapies)
Medical
Management: Rationale: Expected Outcome:
Admit to Pediatric
Oncology unit with
strict neutropenic
precautions.
The patient is presenting with a pediatric
emergency, she is immunocompromised
and requires strict neutropenic precautions
to help prevent the patient from catching
any infections or viruses. The healthcare
team and any visitors should all wear
simple face masks when in the same room
as the patient to prevent her from
contracting anything from others.
Everyone should be frequently washing
their hands and being careful with
cleaning whatever is brought into the
room that the patient will interact with.
Visitors should be limited to family to
reduce her interactions with others who
may be sick or carry an illness to the
patient.
Patient will be protected from potential
sources of pathogens or infection and will not
develop nosocomial infections.12
Daily weight
Documenting daily weight is crucial for
monitoring fluid status and health of the
child in general. This is also important in
determining the child’s medication doses
which will allow for safe medication
administration.
The patient should not lose or gain more
than 3-5% (0.77-1.295kg) of her body
weight each day and once the patient is
hydrated it will be expected that her weight
will increase due to the increase in fluid
volume. Her pulses, cap refill etc. should be
within the normal range. Significant
changes would indicate rapid changes in her
fluid status. each kg lost is 1000ml and she
should not lose more than her intake of
1,548ml/day.
Strict I & 0
Monitoring what the patient intakes and
eliminates will provide accurate data
about the patient’s health status and fluid
status to identify early signs of changes in
her condition. Dehydration, nutrition,
kidney function etc.
The patient will meet her daily fluid intake
of 1,548 ml/day parenterally or by mouth.
She will eliminate at least 25.9ml/hr to
adequately eliminate waste products the
body produces. Her fluid status will also be
monitored by assessing her skin turgor
(immediate), capillary refill (2-3sec), pulses
(2+), blood pressure and for them to be
within normal limits for a 10 year old child.
0.9% NS bolus @
20mL/kg over 60
minutes then D5.45
NaC1 with 20
mEq/L KCL at 2
mL/kg/hr
Proper hydration treatment enhances the
immune system, promotes healing and
helps avoid constipation as it could lead to
further complications. It also aids her
kidneys, liver and other organs to remain
properly perfused as the chemotherapy is
likely affecting their ability to function
and dehydration will lead to more
decreases in their functionality, as shown
in her laboratory values. It is also very
important to hydrate the patient in phases
as children are especially susceptible to
becoming overhydrated and this could
lead to damage in her brain if she quickly
becomes hydrated as it may lead to fluid
overload.
Fluid status and vitals will be evaluated
every 15 to 30 minutes while the patient is
undergoing the hydration treatment. pulses,
blood pressure, urine output, capillary refill,
skin turgor will all show signs of
improvement towards their normal ranges
(see above). Her kidney function should also
shift towards the normal range as she
maintains adequate hydration and perfusion
to avoid stressing out the organs.
Daily blood cultures
from all CVAD
lumens.
Blood cultures must be taken from the
existing CVAD lumens to limit new
breaks in skin that could provide an entry
for pathogenic or potentially lethal
organisms. Use of central venous lines
(tunneled catheter or implanted port) can
effectively reduce need for frequent
invasive procedures and risk of infection.
Myelosuppression may be cumulative in
nature, especially when multiple drug
therapy (including steroids) is prescribed.
Limiting invasive procedures such as
venipuncture as much as possible. Allows
It will be the diagnostic means of
identifying what bacteria is causing her
infection. Her blood cultures will
correspond to the rapid strep test if that is
the source of infection. With her treatment
with ceftriaxone and vancomycin the blood
cultures will begin to show a decrease in the
presence of the infection microorganism. If
her fever is related to the infection, her fever
will reduce as well as the cultures also show
a reduction. Her antibiotic treatment will be
altered with the reduction of her infection
and it will be the indicator that antibiotics13
healthcare team to identify any bacteremia
present in the patient’s system and to
identify what organisms
are invading her circulatory system.
This would allow the doctor to prescribe
antibiotics/medication that
will target any identified microorganism.
Blood cultures are very useful as her fever
and wbc/cmp are also influenced by ALL
and her chemotherapy. If it is a different
bacterium, it would be likely that the CVAD
itself may have been the portal of entry
can be discontinued.
Vital signs every 2
hours and as needed
VS every 2 hours will allow for close
monitoring of the patient for any changes.
This will indicate a worsening or
improving status. Monitoring her vitals
every 15 to 30 minutes while initiating
hydration therapy is also important as she
should be closely monitored for changes
in her hydration status, which would show
in her vitals as well.
The patient’s vital signs will be monitored for
any signs of her condition worsening or
improving in response to treatment.
normal PR: 70-110
normal RR:19
Normal O2: 95-100%
pain: within acceptable range as described by
patient.
normal temperature: 36.7C
Normal BP: around 97 -112 systolic and 57-73
diastolic
Acetaminophen
(160 mg/5 ml)
5ml PO every 4
hours for temp >
100.4 F. (38.0
C.)
Acetaminophen is an antipyretic and will
help reduce the patient’s fever. Reducing
the fever will prevent dehydration and
facilitate proper system function.
The patient will have a temperature less than
100.4 F within 4 hours or a reduction in her
fever. Acetaminophen will be continued
until her temperature is around 36.7C.
Ceftriaxone 75mg/kg
IV every 24 hours.
Cetriaxone is a broad-spectrum antibiotic
that can be administered prior to a throat
culture as an initial anti-infective agent.
Ceftriaxone will help fight the patient's
serious infection and work against the
invading bacteria by inhibiting its
replication. It is commonly used with
vancomycin for systemic infections.
After routine treatment, the patient’s health
status should improve, fever should be
reduced below 100.4F, further cultures
should show reduction or elimination of an
infection, her WBC count should increase as
well near her recent WBC level.
Rapid strep/throat
culture
A throat culture will help identify specific
organisms for appropriate therapy. This
can also verify the presence of the
infection. Sensitivity testing will allow
strategic care planning to incorporate
antibiotics that are effective against the
identified organism to fight off the
infection.
The rapid strep test will identify if
Streptococcus pyogenes is the infecting
microorganism. If so, the child will be
treated with antibiotics like penicillin and
amoxicillin that are very effective against
the bacteria and are very safe to use with
minimal side effects.If the test is negative,
further sensitivity testing will be required to
determine the causative agent, if it is a
bacterial infection.
Vancomycin 15
mg/kg/day, divided
every 6 hours
Vancomycin is given as a very strong antiinfective agent specifically targeting
bacterial infections by stopping bacterial
Peak and trough level will be closely
monitored during her treatment with
vancomycin and it will work to improve her14
growth. It is used with severe infections
and is very effective for bacteremia.
Combined with Ceftriaxone, it is
commonly used when the causative agent
is unknown and the infection is systemic.
With ALL, it is important to immediately
begin treating the suspected infection with
antibiotics and her immune system is
unable to fight off the infection on its
own.
health status by fighting off the infection in
the body. The patient will show signs of
reduction in fever, blood cultures will show
reduction of infection and her WBC will
improve. She should also have a reduction
in pain if it is strep throat and treatment will
help resolve some of the swelling and
irritation caused by the infection. [Show Less]