Acute Lymphoblastic Leukemia (ALL) SKINNY Reasoning case study

April Peters, 10 years old Primary Concept Cellular Regulation Interrelated Concepts (In order 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% 2 3 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 of 4 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