I.
Introduction
I personally selected this case of Acute Myelogenous Leukemia (AML) to enhance my knowledge concerning its clinical manifestations, possible causes, cure and prevention, among others. This knowledge will eventually become an indispensable tool that can be shared to others and will never go out of style. It is a privilege to embrace this challenge in the form of service to humanity and the fulfillment of our nursing profession. Our core competence is the bare essential towards its success. As a nursin nursing g profes professio sion, n, it is impera imperativ tivee to learn learn new techni techniques ques in modern science in order to develop skills that would benefit the medical world. This learning potential must be relayed to posterity and develop new techniques, state -of –the- art technology that caters the modern man. In the final analysis, the achievement of one’s endeavor may usher us to find the light we are seeking for. First of all what is leukemia? Leukemia is a cancer of the blood, and is characterized by uncontrolled proliferation and accumulation of leukocytes (white blood blood cells) cells).. Most Most leukem leukemic ic cells cells never never mature mature into into functi functioni oning ng leukocy leukocytes tes.. Where in the body is deprived of vital components of its immune system. Also, the cells accumulate in the blood and in certain organs, forcing out healthy cells and interfering with the function of that organ. There many different types of leukemia but the four most important forms are derived from only two types of cells, lymphocytes and myelocytes. Acute myelogenous leukemia is disorders of
granulocytes. Granulocytes produced by bone marrow, engulf and digest bacteria and other small particles. This generally appears suddenly with symptoms like those of cold, and progresses rapidly. The lymph nodes, spleen and liver may become become infilt infiltrat rated ed with with leukocy leukocytes tes and enlar enlarged. ged. There is often often bone pain, pain, paleness due to anemia, a tendency to bleed easily because of depleted platelets and high susceptibility to infections. The most common causes of death, which occurs on the average within three months if without treatment, are hemorrhaging and uncontr uncontroll olled ed infect infection ions. s. Acute Acute myelog myelogenou enouss leukemi leukemiaa occurs occurs much much less less frequently in children.
II. Objectives
General Objectives: After 3 days of giving holistic care, the patient will be able to regain optimum level of functioning and adopt coping skills in performing activities of daily living. Specific Objectives: After 8 hours of giving holistic nursing care, the patient will be able to: 1. establi establish sh rappor rapportt with with the stud student ent nurse nurse 2. explain explain reason reasonss of hospit hospitali alizat zation ion 3. state past medical medical history history related related to present present conditi condition on 4. identify identify the precipitat precipitating ing and predisposing predisposing factors factors that that can possibly possibly lead to the occurrence occurrence of the condition 5. discuss discuss the management management applied applied upon the the occurrence occurrence of the disease disease After 8 hours of giving holistic care, the student nurse will be able to: 1. establ establish ish rappor rapportt with with the the patie patient nt 2. presen presentt the patie patient’ nt’ss person personal al histor history y 3. assess assess the the patient’ patient’ss level level of growth and developme development nt 4. show present present profile profile of functio functional nal health patterns patterns
5. discuss discuss with with the patient patient the diffe different rent predispos predisposing ing and precipita precipitating ting factors factors 6. identi identify fy the patho pathophy physio siology logy and and ration rationale ale 7. construct construct a compreh comprehensive ensive nursi nursing ng care plan plan appropriat appropriatee for the the patient patient 8. discuss discuss different different measures measures for home management management
PHYSICAL ASSESSMENT
Body Parts
Inspection
Palpation
HEAD
Round in shape Normocepahlic
No tenderness No Lumps
HAIR
Evenly distributed, Black in color, short, straight hair, smooth
SCALP
No dandruff
FACE
Presence of pimples noted, No wrinkles, brown in color
FOREHEAD
Round, brown in color, No wrinkles, pimples noted
No Lumps noted
EYEBROWS
Black in color, no lesions noted
No Lumps noted
EYELIDS
Closes and opens No Mass noted without difficulty
EYELASHES
Equally distributed
No Lumps noted
Percussion
Auscultation
CONJUNCTIVA
Pale, moist
SCLERA
Opaque in color, c olor, moist
PUPIL
Pupil equally round reactive to light and accommodation, Constricts and dilates
IRIS
Dark brown in color
LACRIMAL
Pale, no discharges
EXTRAOCULAR Moves without EYE any difficulty, MOVEMENT follows the six cardinal gaze LIPS
Pale in color, c olor, symmetrical
No mass noted
MOUTH
Gums are pale, fair in size, dry
No mass noted
TONGUE
Pinkish in color, whitish palate present
TEETH
Yellowish with a complete set of teeth
PALATE
Hard and soft palate are pale in color
UVULA
Rises upon saying “ah”, medially located
TONSILS
Pale in color
NOSE
Has discharges, nasal mucus noted, centrally located, not patent, septum located medially, medially, no lesions, nasal flaring was not noted Symmetrical, ear wax noted, can hear clearly, auricle aligned with outer canthus
EARS
NECK
Brown in color, Carotid pulse: 78 symmetrical, can beats per minute, perform ROM no lumps noted exercises, lymph nodes are not inflamed
SKIN
Brown in color, petechiae was noted in both lower and upper extremities (pin point like appearance), Temperature of 36.8 degree Celsius
EXTREMITIES: UPPER:
CHEST
Without IV, can perform limited ROM exercises, petechiae was noted (pin point like appearance) Equal chest expansion
Vibration felt upon tactile
RR: 24 breaths per minute
BP: 100/60 mmhg
HEART
Clear breath sounds
LUNGS ABDOMEN
LOWER:
fermitus
Brown in color, no abdominal distention Can perform limited ROM exercises, presence of petechiae (pinpoint like appearance) on his both legs
Bowel sounds: 3 upon auscultation
III. Nursing Assessment Assessment 1. Perso ersona nall Hist Histor ory y 1.1Patients Profile Name: Mr. Abella, Fernando Age: 50 years old Sex: Male Civil Status: Married Religion: Roman Catholic Date of Admission: February 04, 2007 Room No. : 532 Complaints: Complaints: tonsillitis Diagnosis: Acute Myelogenous Leukemia Physician: Dr. Ponce, Susie 1.2Family and individual information, social and health history Mr. Mr. Abella Abella,, Fernan ernando, do, 50 yrs. yrs. Old, Old, male, male, Filipin ilipino o Roman oman Cathol Catholic, ic, who is married and has four children, all of which are still schooling. The patient works in a
government government office. The patient is always exposed in petroleum products and paints. Mr. Abella is not hypertensive, diabetic and asthmatic. He is an occasional drinker and a positive smoker which he consumes one pack per day. Mr. Abella was rushed in the emergency room of Cebu Doctor’s University Hospital because he fainted and was very pale. He also complains of tonsillitis.
1.3. Level of growth and Development
Normal Development at Particular Stage
The patient belongs to the middle adulthood. The middle years, from 40 – 65, have been called the years of stability and consolidation. For most people, it is a time when children have grown and moved away or are moving away from home. Thus, partners generally have more time for and with each other and time to pursue interests they may have deferr deferred ed for years. The The mi middl ddle e adu adulth lthood ood,, th the e ind indivi ividua duall mak makes es las lastin ting g con contri tribut bution ions s thro th roug ugh h in invo volv lvem emen entt wi with th ot othe hers rs.. Du Duri ring ng th this is pe peri riod od,, pe pers rson onal al an and d ca care reer er achiev ach ievem ement ents s hav have e of often ten alr alread eady y bee been n exp experi erienc enced. ed. Man Many y mi middl ddle e adu adults lts fin find d part pa rtic icul ular ar jo joy y in as assi sist stin ing g th thei eirr ch chil ildr dren en an and d ot othe herr yo youn ung g pe peop ople le to be beco come me productive and responsible adults. They may also begin to help aging parents. Using leisure time in satisfying and creative ways is a challenge that, if met satisfactory, enables middle adults to prepare for retirement.
Men and women must adjust to inevitable biological changes. As in adolescence, middle adults use considerable energy to adapt self concept and body image imag e to phys physiolo iologica gicall real realitie ities s and chan changes ges in phys physical ical appe appearanc arance. e. High selfesteem est eem,, a fav favora orable ble bod body y im image age,, and a pos positi itive ve att attitu itude de tow towar ard d phy physio siolog logica icall change cha nges s ar are e fos foster tered ed wh when en adu adults lts en engag gage e in ph physi ysical cal ex exer ercis cise, e, bal balanc anced ed di diet, et, adequate sleep, and good hygiene practices that promote vigorous, healthy bodies.
Physical Changes
A number of changes take place during the middle years. At 40, most adults can function as they did in their twenties. However during ages 40 – 65, many physical changes takes place. Both men and women experience decreasing hormonal hor monal producti production on dur during ing the midd middle le year years. s. The menopause menopause ref refers ers to the so called cal led change change of lif life e in wom women, en, wh when en men menstr struat uation ion ceases. ceases. It is sai said d to hav have e occu oc curr rred ed wh when en a wo woma man n ha has s no nott ha had d a me mens nstr trua uall pe peri riod od wi with thin in a ye year ar.. Th The e menopause usually occurs anywhere between ages 40 – 55. The average is about 47 yea years rs.. At thi this s tim time, e, the ova ovarie ries s dec decre rease ase in act activi ivity ty un until til ovu ovulat lation ion cea ceases ses.. Psychologically, the menopause can be anxiety- producing time, especially if the ability to bear children is an integral part of woman’s self concept. The hair begins to thin and gray hair appears. Skin turgor and moisture decrease, subcutaneous fat decreases and wrinkling occur. Fatty tissue is redistributed, resulting in fat deposits in the abdominal area. Skeletal muscle bulk decreases at about age 60. Thinning of
the intervertebral disk causes a decrease in height of about 1 inch. Calcium loss from bone tissue is more common among postmenopausal women. Muscle growth continues in proportion to use. Blood vessels lose elasticity and become thicker. Visu Vi sual al ac acui uity ty de decl clin ines es,, of ofte ten n by th the e la late te fo fort rtie ies, s, es espe peci cial ally ly fo forr ne near ar vi visi sion on (presb (pr esbyop yopia) ia).. Aud Audito itory ry acu acuity ity for hi highgh- fr frequ equenc ency y sou sound nds s (p (pre resb sbycu ycusi sis) s) als also o decreases, particularly in men. Taste sensations also diminish. Metabolism slows, resulting resulti ng in weight gain. Gradual decrease in tone of large intestine may predispose the th e in indi divi vidu dual al to co cons nsti tipa pati tion on.. Ne Neph phrron un unit its s ar are e lo lost st du duri ring ng th this is ti time me,, an and d glomerular filtration rate decreases. Hormonal changes take place in both men and women.
Cognitive Changes
The mid middledle- aged adul adults’ ts’ cogn cognitive itive and inte intellec llectual tual abil abilities ities change very ver y li littl ttle. e. Cog Cogni nitiv tive e pr proce ocess sses es inc includ lude e the act action ion tim time, e, mem memory ory,, per percep ceptio tion, n, learning lear ning,, pro problem blem solv solving, ing, and cre creativ ativity ity.. Reacti eaction on time duri during ng the midd middle le years stays sta ys muc much h th the e sam same e or di dimin minish ishes es dur during ing the lat later er par partt of the middle middle yea years rs.. Memory and problem solving are maintained through middle adulthood. Learning continuous and cab be enhanced by increased motivation at this time in life. Middle-aged adults are able to carry out all the strategies described in Piaget’s phase of formal operations. The experiences of the professi professional, onal, social, and personal life of middle-aged persons will be reflected in their cognitive performance. Thus, approaches to problem solving and task completion will vary considerably in middle-ag midd le-aged ed gro group. up. The middle-aged middle-aged adu adult lt can “reflect “reflect on the past and cur curren rentt experience and can imagine, anticipate, plan and hope”.
Changes in the cognitive function of middle adults are rare except with illness are trauma. The middle adult can learn new skills and information. Some middle adults enter educational or vocational programs to prepare themselves for entering the job market or changing jobs.
Moral Changes During this stage, rules and laws are valued because they maintain social order worth preserving. Morality is guided by higher principles of human conduct. Individuals appreciate the social purposes served by laws. They believe laws should be derived from a democratic consensus. Individuals search their own conscience for universal ethical principles. They do not make up their own rules but instead arrive at abstract principles that all religions or moral authorities might view as compelling or fair. There is a correlation between higher stages of reasoning and higher levels of moral behavior. According to Kohlberg, the adult can move beyond the conventional level to the post conventional level. Kohlberg believes that extensive experience of personal moral choice and responsibility is required before people can reach the postt con pos conven ventio tional nal lev level. el. Kohl ohlber berg g fou found nd tha thatt few of hi his s su subje bjects cts ach achiev ieved ed the highest level of moral reasoning.
Psychosocial Development
The psychosocial changes in the middle adult may involve expected events, such as marital separation. This change may result in stress that can affect the middle adults’ over all level of health. In the middle adult years, as children depart from the household, the family enters the post parental family stage. Time and financial demands on the parents decrease, and the couple faces the task of redefining their own relationship. According to Eriksons’ developmental theory, the prim pr imar ary y de deve velo lopm pmen enta tall ta task sk of th the e mi midd ddle le ye year ars s is to ac achi hiev eve e ge gene nera rati tivi vity ty.. Generativity is the willingness to care for and guide others. If middle adults fail to achieve generativity, Stagnation occurs. This is shown by excessive concern with themselves or destructive behavior toward their children and community.
Spiritual Changes As man grows older he becomes more aware of the outside world. Some conform when they are forced to do so, some are driven by self interests and will do only what they must do to get what they want in return. They violate God’s law regularly, sinning more or less everyday with little remorse. Their spiritual senses are not alert. They are ignorant of God and have no concept of holiness. But as man grows older, he becomes more conscious of how important people really are. “Being good” is now important. He thinks about how other people see him and how they must feel. He realizes that the world runs according to rules. The desire to please
other drives him and when he fails his first response is to justify himself. This faith is based on the beliefs of the community. In adult life many individuals develop a faith that is purely their own individual faith and can deal with the paradoxes and ironies of human existence. A fina fi nall st stag age e of de deve velo lopm pmen entt fi find nds s so some me in indi divi vidu dual als s ma maki king ng a co comm mmit itme ment nt to universal values, such as love and justice. The focus on the value of experience and reflect ref lection ion and inte intellec llectual tual deve developm lopment ent find finds s a str strong ong para parallel llel in the impo importan rtance ce given to the rule of experience and reflection in spiritual growth. growth.
Sexuality Changes Aft fter er th the e de depa part rtur ure e of th thei eirr la last st ch chil ild d fr from om th the e ho home me,, ma many ny co coup uple les s reculti rec ultivate vate thei theirr rel relation ationship ships s and find incr increased eased mari marital tal and sexu sexual al satis satisfact faction ion during middle age. The onset of menopause and the climacteric can affect the sexual sex ual sati satisfac sfaction tion duri during ng the midd middle le adul adult. t. Othe Otherr facto factors rs infl influenc uencing ing sex sexuali uality ty during this period include work stress, diminished health of one or both partners, and the use of prescription medications. medications.
Diagnostic Test
Normal Value
Result
Significance
Hemoglobin
14-17.5gm/dL
6.77gm/dL
Hematocrit
14-17.5
19.3
4.4-11.0
174,000
3%
02%
56%
05%
0.3%
--
2.7%
--
34%
07%
WBC Band Segmenter Basophil Eosnophil
Increased: Infection Decreased: Decreased: NORMAL NORMAL Decreased: Immuno –
Lymphocyte 4%
61%
4.5-5.9 10 12/L
1.93 10 12/L
80-96fL
100fL
Monocyte
RBC
Decreased: Anemia Increased: Erythrocytosis
MCV 27.5-33.2pg
35.1 pg
MCH 33.4-35.5%
MCHC
--
MPV
--
RDW
150,000-
Platelet Count
450,000/cu mm
0.5-1.5%
Reticulocyte
0.00-20.00mm/h
ESR
0.7-1.5mg/dL
Creatinine Serum
3.6-5.0mmol/L
Potassium
11-66uL
ALT ALT
137-145mmol/L
Sodium 2.5-7.5mg/L
35.0% ---
deficiency Increased: Viral infections Decreased: Anemia Increased: Macrocytic Anemia Increased: : Macrocytic Anemia NORMAL NORMAL NORMAL
27,020/cu mm Decreased: Acute Leukemia
--2.1 mg/dL 3.0 mmol/L 59 uL
NORMAL NORMAL Increased: Fever Decreased: Diarrhea
134 mmol/L NORMAL
11.9 mg/L
Decreased: Metabolic Acidosis Increased: Gout
Uric Acid
Present Profile of the Functional Health Patterns
3.1 Health Perception Pattern Before the patient was diagnosed with Acute Myelogenous Leukemia the patient describes himself as a healthy individual. But as of now, he describes his condition as very poor due to his present condition. In order for him to keep healthy, he must must eat nutri nutritio tious us foods foods and must must not not over over fatigu fatigue e hims himself elf.. He follow follows s the doctor doctors s order order and take take the medi medicat cation ion as needed needed.. The patien patientt refus refuses es to have have chemotherapy due to financial problems.
3.2 Nutritional Metabolic Pattern Before the patient was not admitted in the hospital, he likes to eat any kind of foods. But as of now, the patient does not want to eat and he vomits all the time. The patient drinks alcohol mostly everyday, he prefers to drink Tanduay and Emper Emperado adorr. The patien patientt also also smoke smokes s and can consu consume me one pack pack per day. The The patient takes vitamin supplements like Revicon and Everet. According According to the patient his weight had decreased from 180 pounds to 110 pounds.
3.3 Elimination Pattern On the first week of his admission, the patient was having hematuria and melena. After the following weeks, the patient’s foley bag catheter was
already removed and the patient was having no problems in urinating and defecating. The patient defecates once in a day. 3.4 Activity or Exercise Pattern Before, the patient used to walk from his home to his office, but now even five steps he feels fatigue and will have a difficulty in breathing. The patient was advised by the physician not to over fatigue himself and he needs enough sleep and rest.
3.5 Cognitive or Perceptual Pattern The patient cannot see from far objects. He wears eyeglasses so that he can see clearly. The patient can hear well enough. The patient often times complains of fatigue and feels drowsy all the time. The patient is able to read and write.
3.6 Sleep or rest Pattern Before the patient’s hospitalization, he sleeps at 7: 00 pm to 6:00 in the morning, but now because of his condition he sleeps most of the time. The patient has no problem in sleeping.
3.7 Self Perception Pattern The patient is concerned about his illness. He is scared that he will die and might be far away from his family. family. According to the patient, he wants to be free
from Leukemia but it is too impossible to happen, it needs some miracles. The patient describes himself as very religious especially with his condition and he must need some faith to hold on to whatever circumstances might happen. His condition made him different because unlike normal people he needs to wear a mask all the time.
3.8 Role Relationship Pattern The patient prefers to speak Cebuano. He speaks clearly and fluently and he is able to express himself himself freely. freely. The patient lives with his family family in Matabang Toledo City.
3.9 Coping or stress Tolerance Pattern The patient and his wife both make the decision especially when it comes to health and financial matters. He sometimes seeks help to his mother when it comes t o problem solving because he is more comfortable in asking for assistance so that he can express express his feelings. The patient is still working but he will just go to work to punch in and leave.
3.10 Value or belief System The patient is a Roman Catholic and God is very important to him. For him, God and his family is his source of strength and meaning. The patient prays the rosary and attends mass every Sunday. The patient wishes to go to Simala to
pray for his condition. According to the patient, he just accepts what Gods plan awaits him.
IV. Pathophysiology and Rationale
Anatomy and Physiology
The immune system defends the body from invading organisms that may cause disease. One part of the immune system uses barriers to protect the body from foreign substances. These barriers include the skin and the mucous membranes, which line all body cavities; and protective chemicals, such as enzymes in saliva and tears that destroy bacteria. Another part of the immune system uses lymphocytes, specialized white blood cells that respond to specific types of foreign invaders. B lymphocytes produce proteins called antibodies, which circulate in the blood and attack specific disease-causing organisms. T lymphocytes attack invading organisms directly.
COMPONENTS OF THE IMMUNE SYSTEM Macrophage Engulfing Bacterium
A macrophage, in yellow, engulfs and consumes a bacterium. Macrophages are are large large phago phagocyt cytes, es, cells cells that that wander wander throu through gh the body body consum consumin ing g forei foreign gn particles such as dust, asbestos particles, and bacteria. They help protect the body against infection.
White blood cells are the mainstay of the immune system. Some white blood cells, known as macrophages, play a function in innate immunity by surrounding, ingest ingestin ing, g, and destr destroyi oying ng invad invading ing bacter bacteria ia and other other foreig foreign n organ organism isms s in a proce process ss called called phagocytosis (lit (liter eral ally ly,, “cel “celll eati eating ng”) ”),, whic which h is part part of the the inflam inflammat matory ory react reaction ion.. Macro Macropha phages ges also also play play an impo importa rtant nt role role in adapti adaptive ve immunity in that they attach to invading antigens and deliver them to be destroyed by other components of the adaptive immune system.
LYMPHOCYTE
Lymphocytes are specialized white blood cells whose function is to identify and destroy invading antigens. All lymphocytes begin as “stem cells” in the bone marrow, the soft tissue that fills most bone cavities, but they mature in two different different plac places es.. Some Some lymp lympho hocy cyte tes s matu maturre in the the bone bone mar marrow and and are are call called ed B lymphocytes. B lymphocytes, or B cells, make antibodies, which circulate through the blood and other body fluids, binding to antigens and helping to destroy them in humoral immune responses. Other lymphocytes, called T lymphocytes, or T cells, mature in the thymus, a small glandular organ located behind the breastbone. Some
T lymphocytes, called cytotoxic (cell-poisoning) or killer T lymphocytes, generate cell-m cell-medi ediate ated d immu immune ne respo respons nses, es, direct directly ly destr destroyi oying ng cells cells that that have have speci specific fic anti antige gens ns on thei theirr surf surfac ace e that that are are recog ecogni nize zed d by the the kill killer er T cell cells. s. Help Helper er T lymphocytes, a second second kind of T lymph lymphocy ocyte, te, regulat regulate e the immune immune system system by controlling
the
strength
and
quality
of
all
immune
responses.
Most contact between antigens and lymphocytes occurs in the lymphoid organs— organs — the lymph nodes, spleen, and tonsils, as well as specialized areas of the intestine and lungs (see ( see Lymphatic System). Mature lymphocytes constantly travel through the the bloo blood d to the the lymp lympho hoid id orga organs ns and and then then back back to the the bloo blood d agai again. n. This This reci recirc rcul ulat atio ion n ensu ensure res s that that the the body body is cont contin inuo uous usly ly moni monito tore red d for for inva invadi ding ng substances.
BONE MARROW
Bone Marrow, Marrow, soft, soft, pulpy pulpy tissu tissuee that fills the cavities cavities of bones, occurring in two forms, forms, red and yellow. One of the largest tissues in the body, bone marrow accounts for 2 to 5 percent of an adult’s weight. Red marrow, present in all bones at birth, serves as the blood manufacturing
center. As an infant matures, most of the red marrow in the shaft of long bones, such as the arm and leg bones, bo nes, is gradually replaced by yellow marrow. Yellow Yellow marrow is composed primarily of specialized fat cells.
STRUCTURE
Red marrow consists primarily of a loose, soft network of blood vessels and protein fibers interspersed with developing blood cells. The blood vessels are termed the vascular component, and the protein fibers and developing blood cells collectively are referred to as the stroma, or the extravascular component. The protein fibers crisscross the marrow, forming a meshwork that supports the developing blood cells clustered in the spaces between the fibers. Red marrow marrow contai contains ns a rich rich blood blood supply supply.. Arteri Arteries es transp transport ort blood blood contain containing ing oxygen oxygen and nutrients into the marrow, and veins remove blood containing carbon dioxide and other wastes. The arteries and veins are connected by capillaries, blood vessels that branch throughout the marrow marrow.. In various various places, places, the capillaries capillaries balloon out, forming forming numerous numerous thin, blood-filled blood-filled cavities. These cavities are called sinusoids, and they assist in blood-cell production.
Yellow marrow is so named because it is composed of yellow fat cells interspersed in a rich mesh of connective tissue that also supports many blood vessels. While not usually actively involved in blood formation, in an emergency yellow marrow is replaced by blood-forming red marrow when the body needs more blood
MARROW FUNCTION
Red marrow produces all of the body’s blood cells—red blood cells, white blood cells, and platelets. Red blood cells in the circulatory system transport oxygen to body tissues and
carbon dioxide away from tissues. tissues. White blood cells are critical for fighting bacteria and other foreign invaders of the body .Platelets are essential for the formation of blood clots to heal wounds. Within red bone marrow, all blood cells originate from a single type of cell, called a hematopoietic stem cell. Stimulated by hormones and growth factors, these stem cells divide to produce immature, or progenitor blood cells. Most of these progenitor cells remain in the stroma and rapidly undergo a series of cell divisions, producing either red blood cells or white blood cells. At any one time, the stroma consists largely of progenitor cells in various stages of development. development. At the appropriate appropriate developmental developmental stage, stage, the fresh, new cells squeeze squeeze through through the walls of the capillaries. From there, the cells leave the bone and enter the body’s circulatory system. Some progenitor cells migrate to the sinusoids, where they produce platelets, which also travel to the circulatory system via the capillaries. Although stem cells are relatively rare—about 1 in every 10,000 marrow cells is a stem cell—they typically produce the forerunners of an estimated 2 million red cells per second and 2 billion platelets per day. However, if significant amounts of blood are lost or other conditions reduce the supply of oxygen to tissues, the kidneys secrete the hormone erythropoietin. This hormone stimulates stem cells to produce more red blood cells. To fight off infection, hormones collectively termed colony stimulating growth factors are released by the immune system. These hormones stimulate the stem cells to produce more infection-fighting white blood cells. And in severe cases, the body converts yellow marrow into red marrow to help produce needed blood cells.
PREDISPOSING FACTORS
4.3 Discuss the disease process ands its effects on different organ/system
Leukemia Overview CANCER Cancer Canc er is a proces processs of uncontr uncontroll olled ed abnorma abnormall cell cell growth growth and developm development ent.. Under Under normal circumstances, cells are formed, mature, carry out their intended function, and then die. New cells are constantly regenerated in the body to replace those cells and to maintain normal cellular cellular function. Cancer represents the disturbance disturbance of this process, process, which can occur in several several ways.Cells may grow and reproduce in a disorganized and out-of-control fashion. Cells may fail to develop properly, so they will not function normally. Cells may fail to die normally. One or a combination of these processes may occur when cells become cancerous.
LEUKEMIA Leukemia is a cancer cancer of bloodblood-for formin ming g cells cells in the bone marrow marrow.. These These derange deranged, d, immature cells accumulate in the blood and within organs of the body. They are not able to carry out the normal functions of blood cells. Normal blood contains 3 major groups of cells: white blood cells, red blood cells, and platelets. All 3 types of blood cells develop from one immature cell type, called blood/marrow stem cells, in a process called hematopoiesis. •
These stem cells divide and develop to a more developed, but still immature precursor, called a blast, which then develops through several more stages, into a mature blood cell.
•
This This proce process ss takes takes place place in the the bone bone marro marrow, w, which which is the soft soft spongy spongy material found in the center of most bones.
Each type of blood cells has its own different and essential function in the body. •
White blood cells (leukocytes) are are part of the immune system and help fight a variety of infections. They also help in the t he healing of wounds, cuts, and sores.
•
Red blood cells (erythrocytes) contain hemoglobin, hemoglobin , which carries oxygen to, and removes carbon dioxide from, the cells throughout the various organs of the body.
•
Platelets, along with certain plasma proteins, help plug the holes in blood vessels and form clots once blood vessels are damaged or cut.
The first step in the process of stem cell maturation is differentiation into 2 groups: the myeloid stem cell line and the lymphoid stem cell line. •
The myeloid stem cells, or lineage, develop into red blood cells, platelets, and certain types of white blood cells (granulocytes or monocytes).
•
The lymphoid stem cells, or lineage, develop into another type of white blood cell (lymphocytes).
•
Either lineage can be affected by leukemia. Leukemias that affect the myeloid line lineag age e
are are
call called ed
myel myeloc ocyt ytic ic
(als (also o
myel myelog ogen enou ous, s,
myel myelob obla last stic ic,,
or
nonlymphocytic) leukemias. Leukemias that affect the lymphoid lineage are called lymphocytic (also lymphoblastic or lymphogenous) leukemias. Each of the 2 major types of leukemia, myelogenous and lymphocytic, include both acute and chronic forms. •
Acute essentially refers to a disorder of rapid onset. In the acute myelocytic leukemias, the abnormal cells grow rapidly and do not mature. Most of these immatu immature re cells cells tend tend to die die rapidl rapidly y. In the acute acute lympho lymphocyt cytic ic leuke leukemi mias, as, growth is not as rapid as that of the myelocytic cells. Rather, Rather, the cells tend to accumulate. Common to both types of leukemia is their inability to carry out the function functions s of healthy healthy white white blood blood cells. cells. Untreated Untreated,, death occurs within weeks or a few months.
•
In the chronic leukemias, the onset tends to be slow, and the cells generally mature abnormally and often accumulate in various organs, often over long intervals. Their ability to fight infections and assist in repairing injured tissues is impaired. However, unlike the acute forms of leukemia, untreated, these disorde disorders rs may persist persist for many months months or, as in the chronic chronic lymphocyt lymphocytic ic group, many years. A distinctive feature of the chronic myelocytic type is its invariable conversion, if untreated, to a more rapidly fulminating acute type, leading to rapid death.
WHAT HAPPENS IN LEUKEMIA? When a large number of blasts (leukemic cells) appear in the bone marrow, marrow, several things happen. As the leukemic blast cells accumulate in the bone marrow, they begin to crowd out the normal blood cells that develop there. Eventually, they take up so much room that red blood cells, platelets, and normal white blood cells cannot be produced. When that happens, the young person develops symptoms indicating that normal blood cells are not being manufactured in adequate numbers: •
If red blood cells are crowded out by leukemic cells, the blood will look thin, which makes the patient look pale. The young person also may be tired,
because the thin blood cannot carry enough oxygen to the heart, lungs, and muscles. •
If blood platelets are crowded out in the bone marrow, the young person may have bleeding problems and unusual bruising.
•
If the normal, mature kind of white cells known as neutrophils are crowded out by the blasts, there will be no cells to combat bacteria, and infections may occur oc cur.. In some cases, leukemic blasts may spill over from the bone marrow into the blood, where they can be seen by microscopic examination. examination. This may cause a rise in the number of white cells in the blood (the white blood cell count). In other cases, only a few blasts appear in the blood, and the white cell count does not change much. When leukemic blasts are present in the blood, they may be carried to other places in the body and enter various body organs. Some Someti time mes s they they grow grow in thes these e orga organs ns as well well as in the the bone bone marr marrow ow..
Cancer cells
ACUTE MYELOGENOUS LEUKEMIA
Normal cells
A PICTURE OF ACUTE MYELOGENOUS LEUKEMIA Acute myelogenous leukemia (AML) is a cancer of the blood and bone marrow — the spongy tissue inside bones where blood cells are made.
It's called acute leukemia because it progresses rapidly and affects immature blood cells, rather than mature ones. It's called myelogenous (MI-uh-loj-uh-nus) leukemia because it affects a group of white blood cells called the myeloid cells, which normally develop into the various types of mature blood cells, such as red blood cells, white blood cells and platelets. This type of leuke leukemi miaa is also also known known as acut acutee myelo myeloid id leuke leukemi mia, a, acute acute myel myelobl oblas asti ticc leuke leukemi mia, a, acut acutee granulocytic leukemia and acute nonlymphocytic nonl ymphocytic leukemia. Normally, your bone marrow produces immature cells (stem cells) in a controlled way, and they mature and specialize into the various types of blood cells as needed. In people with acute myelogenous leukemia, the bone marrow produces immature cells that usually develop into a type of abnormal white blood cell. These abnormal cells aren't able to mature and perform their usual functions. Even worse, they multiply rapidly and can crowd out healthy cells, leaving a person with acute myelogenous leukemia vulnerable to infection, anemia or easy bleeding. Leukemia cells can also spread outside the blood to other parts of your body.Acute myelogenous leukemia is the most common form of leukemia. It worsens quickly if not treated, but it initially respon responds ds well well to treatm treatment ent.. Unfort Unfortuna unately tely,, many people people with with acute acute myelog myelogenou enouss leukem leukemia ia experience experience a relapse. relapse. Much research research is focused focused on decreasing the risk of relapse relapse and improving improving the long-term outcomes for people with acute myelogenous leukemia CAUSES
The cause of acute myelogenous leukemia is damage to the DNA of developing cells in your bone marrow. Under normal circumstances, your DNA is like a set of instructions for your cells, telling them how and when to grow and divide. Certain genes on your DNA called oncogenes promote cell division. Other genes, called tumor suppressor genes, slow down cell division and cause cells to die at a t the appropriate times. Acute myelogenous leukemia can occur when damage to DNA turns on oncogenes or turns off tumor suppressor genes. When this happens, blood cell production goes awry. The bone marrow produces immature cells that develop into leukemic white blood cells called myeloblasts. These abnormal cells are unable to function properly, and they can build up and crowd out healthy cells.The DNA mutations that cause leukemia are usually acquired — rather than inherited — but researchers and doctors don't always understand exactly how. In some cases, damage to DNA is the result of exposure to cancer-causing chemicals, including previous chemotherapy for other cancers. There's also a chance of AML progressing from other blood diseases and chronic leukemias, leukemias, such as chronic chronic myelogenous myelogenous leukemia, myelodysplasi myelodysplasiaa or other disorders disorders in which the bone marrow marrow produc produces es too much much of certain certain types types of blood blood cells cells (myelop (myeloprol rolife iferat rative ive disorders).
RISK FACTORS The risk of acute myelogenous leukemia increases with age. It's most prevalent in people in their 60s and older. The disorder is also more common in males than in females. Other possible risk factors include: •
Cancer therapy. therapy. Peopl People e who'v who've e had certai certain n types types of chemo chemothe therap rapy y and radiatio radiation n therapy therapy or treatme treatment nt for childhoo childhood d acute acute lymphocyt lymphocytic ic leukemia leukemia (ALL) may have a greater risk of developing AML.
•
Exposure to radiation and certain chemicals. People exposed to very high high levels levels of radiat radiation ion,, such such as survi survivor vors s of an atomic atomic bomb blast or a
nuclear reactor accident, have an increased risk of developing AML. Exposure Exposure to certain chemicals, such as benzene — which is found in unleaded gasoline and used by the chemical industry — also is linked to greater risk of AML. •
Smoking. AML is linked linked to cigarett cigarette e smoke, smoke, which which contains contains benzene and other known cancer-causing cancer-causing chemicals. Smokers older than 60 face twice the risk of AML that nonsmokers do.
•
Other blood disorders. disorders. People who've had another blood disorder, such as myelodysplasia, myelodysplasia, polycythemia vera or thrombocythemi thrombocythemia, a, are at greater risk of developing AML.
•
Genetic disorders. Certain genetic disorders, such as Down syndrome, are associated with an increased risk of AML.
CLASSICAL SYMPTOMS
CLINICAL SYMPTOMS
RATIONALE
Anemia
•
•
•
Manifested
Dyspnea
During the assessment,
Fatigue
the student nurse
Pale skin, mucous membrane, conjunctiva, nail beds
observed that the patient has a pale skin, oral mucosa, conjunctiva and nail beds. The patient also verbalizes that he feels weak and sometimes he had difficulty in breathing even doing things with no exerted force.
More specific signs and symptoms of acute myelogenous leukemia are caused by a lack of properly functioning blood cells, resulting from overcrowding by leukemia cells. The oxygen carrying capacity of hemoglobin is reduced causing tissue hypoxia and can result to fatigue, weakness and dyspnea (p. 276 disease management for nurse practitioner by: Scilling) In acute melogenous leukemia, there is the loss of bone marrow
Thrombocytopenia Manifested
function because of the The patient had a low platelet count levels
replacement of the malignant cells such as
(27,020cu mm)
occurs in leukemia, which results in decrease production of platelets (p. 265 disease management for nurse practitioner by: Scilling) In acute myelogenous leukemia, bleeding is evident because of a
•
Bleeding
Manifested
decrease circulating platelets or impaired
One week prior to admission,, the patient admission experiences hematuria and bloody stools. The patient also has petechiae in his surrounding skins.
platelet function. Bleeding that results from platelet deficiency commonly occurs in small vessels and is characterized by petechae and purpura (p. 265 disease management for nurse practitioner by: Scilling)
In acute myelogenous leukemia, the bone marrow produces immature cells that Manifested
usually develop into a type of abnormal white
Neutropenia
The patient was advised blood cell. These
•
infection
by his physician to wear abnormal cells aren't mask all the time and able to mature and must eat foods that ca perform their usual boost his immune functions. Even worse, system they multiply rapidly and can crowd out healthy cells, leaving a person with acute myelogenous leukemia vulnerable to infection (http://www.mayoclinic.c om) The symptoms of AML are caused by low numbers of healthy Manifested
blood cells and high numbers of leukemia
The patient had fever
•
fever
one week prior to his
cells. White blood cells
admission because of
fight infection. Low
massive tonsillitis
numbers can lead to fever and frequent infections. With immunosuppression the body the body is often unable to respond an infection with a characteristic characteristic indicator, such as fever (http://www.marrow.org) (p. 660 Nursing Care of acutely ill and chronically ill patient by: Lagerquist)
In patient who is immune-suppressed, the oral mucous membranes Manifested The patient complains of having difficulty in
are often a source of infection; therefore a complain of a sore throat is an important of
•
tonsillitis
swallowing because of
early indication of a
tonsillitis.
potential problem
(p. 660 Davis’s NCLEXRN Success by: Lagerquist) These is because of the proliferation of leukemia cells within organs
Not Manifested
(p. 897 medical- surgical nursing by: Brunner)
Not Manifested Not Manifested
Spleenomegaly Hyperplasia of the gums Bone pain
Nursing Interventions
1. Care Care Guide in in Patient Patient with with diseas disease e Condition Condition
TREATMENT
Treatment of patients with acute myelogenous leukemia depends on age and the subtype subtype of the disease. In general, treatment falls into two phases:
•
Remission induction therapy. therapy. The purpose of the first phase of treatment is to kill kill the the leuk leukem emia ia cell cells s in your your bloo blood d and and bone bone mar marrow row. Howe Howeve ver, r, remission induction usually doesn't wipe out all of the leukemia cells, so you need further treatment to prevent the disease from returning.
•
Consolidation therapy. therapy. Also called called post-rem post-remissi ission on therapy, therapy, maintena maintenance nce therapy or intensification, this phase of treatment is aimed at destroying the remaini remaining ng leukemia leukemia cells. It's considered considered crucial to decreasi decreasing ng 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), follow followed ed by an anthra anthracyc cyclin linee drug, drug, such such as daunoru daunorubic bicin in (Cerub (Cerubidi idine) ne) or idarub idarubici icin n (Idamycin). A third medication, thioguanine, is sometimes used.
If you have AML, you'll probably stay in the hospital during the treatment cycle because the chemotherapy destroys many normal blood cells in the process of killing leukemia cells. This chemotherapy can cause anemia, infection and bleeding. If the first cycle of treatment doesn't cause remission, you may need it repeated one or two more times. Other drug combinations also may be used, depending on your 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. Your doctor may also prescribe medicat medication ionss that that boost boost white white cell cell product production ion to reduce reduce the risk risk of infecti infection. on. These These medications are called granulocyte colony stimulating factors (Neupogen, Leukine).
•
Other drug therapy. Arsenic trioxide and all-trans retinoic acid (ATRA) are anti anti-c -can ance cerr drug drugs s that that can can be us used ed alon alone e — or in comb combin inat atio ion n with ith chemotherapy — for remission induction of a certain subtype of AML called promyel promyelocyti ocytic c leukemia leukemia.. These These drugs drugs cause cause leukemia leukemia cells with a specific specific gene mutation to mature and die, or to stop dividing.
•
Biological therapy. Also known as immunotherapy, biological therapy uses subs su bsta tanc nces es that that
bols bolste terr
your your immu immune ne syst system em's 's respo espons nse e
to canc cancer er..
Monoclonal antibodies are one form of biological therapy. These antibodies are produced in a laboratory, but they mimic protein products found in your immune immune system system (antibodi (antibodies) es) that attack attack foreign foreign substance substances s (antigen (antigens) s) on leukemic cells. Gemtuzumab ozogamicin (Mylotarg) is a monoclonal antibody linked to a chemical toxin that attaches to AML cells. It's used to treat older people with AML who don't respond to initial treatment or who relapse after succes successfu sfull initi initial al treat treatmen ment. t. Resear esearch chers ers are are testin testing g its effect effective ivenes ness s in younger people with AML. •
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 replaci replacing ng their their leukemic leukemic bone marrow marrow with leukemia leukemia-fre -free e marrow marrow.. If you
choose this treatment, you'll receive very high doses of chemotherapy or radiatio radiation n therapy therapy to destroy destroy your leukemia leukemia-pro -produci ducing ng bone marrow marrow.. This marrow is then replaced by bone marrow from a compatible donor (allogeneic transplant). In some cases, you may also be able to use your own bone marrow for transplant (autologous transplant). This is possible if you go into remission and then save healthy bone marrow for a future transplant. •
Stem cell transplant. Stem cell transplant is also used for consolidation therapy therapy.. It's similar similar to bone marrow marrow transpla transplant nt except except the stem cells are collected from circulating 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 your 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 Radiation Therapy Therapy .Radiation therapy involves the use of radiation to kill cancer cells
external radiation radiation and shrink tumors. For AML, external radiation therapy is used.In external therapy radiation is directed at the tumor from a source outside the body. This type of treatment is used for AML that 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.
NCP
s- “ dali na kayo ko kutasan ug kapuyan na ko dae, mga lima ka lakang kapuyon na ko” as verbalized by the patient
o-
weakness
-feeling of exhaustion -low RBC counts: 1.93 - low hemoglobin count: 6.77 -shortness of breath -fatigue -blood pressure: 100/60 mmhg
A-
Activity Intolerance: fatigue related to anemia
P-
demonstrate a decrease in physiologic signs of intolerance
I-
plan care with rest periods between activities
elevate head of bed as tolerated
provide positive atmosphere, while acknowledging acknowledging difficulty of the situation of the patient
provide quiet environment, maintain bed rest as indicated. Limit visitors, phone calls and reported unplanned interruptions
prioritize nursing care schedules to enhance rest.
use energy techniques such as shower chair, sitting performing task
provide assistance assistance with patient, including activities that the patient views as essential. Increase activity levels as tolerated
instruct patient to stop activity if palpitations, chest pains, shortness of breath, weakness, dizziness occur
change patient position slowly and monitor for dizziness
E-
the patient shows a decrease signs of intolerance
s-
“ ingon si doc dae na pa mason ko niya kai para dili ko ma takdan sa mga
sakit” As verbalized by the patient
o-
increase increase white blood cells:174,000
presence of immature leukocytes compromised immunity wears mask low eosinophil: 0% low lymphocyte: 07%
A-
Risk for infection related to proliferation proliferation of immature lymphocytes
P-
the client will be free from acquiring infection
I-
maintain a fluid intake of at least 2500 ml per day
use good handwashing technique and encourage patient to do the same
protect client from others with infections
instruct and assist client to perform good oral hygiene as often as needed
instruct patient to wear mask all the time
eliminate fresh salads and unpeeled fresh fruits and vegetables
allow no fresh flowers
administer antimicrobials antimicrobials as needed
E-
the patient shows a decrease signs of intolerance
s-
“ pait kaau ning akong kahimtang, naa pa koi mga anak nga gagmay sa tanan
ako pa jd wala mn me kwarta” As verbalized by the patient
o-
sad facial expression crying
A- Anticipatory grieving related to possible loss of loved one P-
will be able to express feelings of anxiety
I-
encourage verbalization of fears, concerns and questions regarding disease
treatment
encourage active participation of patient or family in care and treatment decisions
be with patient most of the times
encourage verbalization verbalization of negative feelings, including anger and hostility
allow periods of crying and expression of sadness
use therapeutic communication skills of active listening, silence, acknowledgement
advise for professional professional counseling
permit verbalization of anger with acknowledgement of feelings and setting of limits regarding destructing behavior
E-
the patient was able to verbalize feelings of anxiety
OBJECTIVES
CONTENTS
METHODOL OGY
GOAL: After 3 days of varied teaching and learning experience, the patient and significant others will be able to gain knowledge, attitude and skills about his disease condition and how to prevent fatigue. After 45 minutes of student nurse-patient interaction, the patient will be able to: 1. identify predisposing factors in acquiring leukemia
2. enumerate signs and symptoms of leukemia
1. predi predisp spos osin ing g fact factor orss in in acquiring leukemia 1.1 expose to to radiation radiation for a long period 1.2 genetic genetic factors factors such as as down syndrome 1.3 exposure exposure to chemical chemicalss such as benzene and drugs that causes aplasic anemia
Informal discussion
Informal 2. sign signss and and symp symptom tomss of of discussion leukemia 2.1 fever and infection infection related to decrease in white blood cells 2.2 weakness weakness and fatigue fatigue from anemia 2.3 bleeding bleeding tendencies tendencies from from decreased platelets
EVALUATION
3. dete determ rmiine the the significance on wearing a mask all the time 4. the the pat patie ient nt will will show interest during the health teaching
5. dem demons onstrat tratee beginning skills on preventing fatigue by clustering scheduled activities
3. sign signif ific ican ance ce on on wear wearin ing g Informal mask all the time discussion 3.1 this is is to prevent prevent the the patient from acquiring any infection 4. show showss inte intere rest st dur durin ing g the the Informal health teaching discussion and 4.1 asks questio questions ns during the the utilization of interaction of the student pictures nurse 4.2 participates participates and encourages the student nurse to go on to the discussion 4.3 Shows Shows interest interest on the discussion by cooperating with the student nurse 5. clus cluste teri ring ng sche schedul duled ed activities 5.1 teach client client on how to cluster activities to prevent fatigue example: Monday: 7:00-7:30 (eating breakfast) 7:30 – 9:00 watching television for relaxation 9:00-9:30 perform exercise such as walking 9:30-10:00 reading books … 5.2 let the patient decide and schedule his planned activities
Scheduling activities and Informal discussion
VII. Evaluation and Recommendation:
Early Early detectio detection n of an ailmen ailmentt is vital vital to the patient patient..
Oftenti Oftentimes mes lack lack of in-dept in-depth h
knowledge regarding a condition of a disease may hinder a patient in seeking immediate advice from medical specialist. Fear and financial problems may sometimes interfere which may often lead to the severity of the disease. This I believe is one of the major causes as to why my patient has gone to this terminal stage of his Acute Myelogenous Leukemia (AML). The nature of his job as a painter exposes him to great risk of an organ damage. Petroleum products when exposed to a person to a considerable period of time may often lead a person to this problem. This is also coupled with lack of knowledge regarding this health hazard. According to his recent laboratory results, his platelet is 27,000 /cu mm which is very low compared to the normal platelet count of 150,000-450,000/ cu mm. This shows a decrease in both platelets and erythrocytes. The patient shows hematuria, melena and petechiae on his both upper and lower extremities, this is an indication of decrease in platelet as well. Because of lack of mature and normal granulocytes, the patient had a massive tonsillitis. Since treatment for chemotherapy chemotherapy is too costly for the patient this could contribute contribute for a compelling compelling severity of his health condition. It is necess necessary ary to undert undertake ake sessio sessions ns of chemoth chemothera erapy py to prolon prolong g the patien patient’ t’ss life. life. Immaturity of leukocytes can also lead to severe infection, the patient is encouraged to wear mask whenever the condition necessitates. The patient needs proper rest due to fatigue. He also needs more encouragement from his immediate family member, relatives and friends.
Government sector plays a great role in sustaining financial support for indigent patients. Health care institutions can also help in the financial assistance of their members. Advancement of medical technology and profession is always a mileage in the science of medical world.
DTR
VII. Bibliography
Porth, Carolwatson.” Pathophysiology”.6th edition. Schilling, Judith A. RN, MSN “ Disease management for Nurse Practitioners”. Smeltzer, Smeltzer, Suzanne. Bare, Brenda. “Medical-Surgical Nursing. 10th edition. Lippincott Wiliams and Wilkins. Lagerquist, Sally. Sally. “ Nclex-RN Success” F.A. Davis Company Marieb Marieb,, Elaine Elaine.. “Essen “Essentia tials ls of Human Human Anatomy Anatomy and physio physiology logy”” education Inc., San Francisco, California. 2003. Smeltzer. Smeltzer. Bare. “ Medical-Surgical Nursing”. 10th edition. Patrick. “ Medical-Surgical Nursing”. 2nd edition. Phipps. Long. Woods. “Medical-Surgical Nursing”
INTERNET: http://healthgate.partners.org www.mayoclinic.com www.cancerlinkusa.com www.niaid.nih.gov]] www.niaid.nih.gov Microsoft encarta 2006 PremiuM
7th edition.Pearon
