Question

C.O. is a 43-year-old woman who noted a nonpruritic nodular rash on her neck and chest about 6 weeks ago. The rash became generalized, spreading to her head, abdomen, and arms, and was accompanied by polyarticular joint pain and back pain. About 2 weeks ago, she experienced three episodes of epistaxis in 1 day. Over the past week, her gums became swollen and tender and she was severely fatigued. Because of the progression of symptoms, she sought medical attention. Lab work was done, and C.O. was directly admitted to the hematology/oncology unit under the care of a hematologist for diagnostic evaluation. Skin biopsy showed cutaneous leukemic infiltrates, and bone marrow biopsy showed moderately hypercellular marrow and collections of monoblasts. Her lumbar puncture specimen was free of blast cells. The final diagnosis was acute myeloblastic leukemia.

C.O. is to begin remission induction therapy with cytarabine 100 mg/m2/day as a continuous infusion for 7 days and idarubicin 12 mg/m2/day IV push for 3 days. She is scheduled in angiography for placement of a triple-lumen subclavian catheter before beginning her therapy.

Laboratory Test Results

Complete Blood Count (CBC)

White blood cells (WBCs) 39,000/mm3 (39 x 109/L)

Monocytes 64%

Lymphocytes 15%

Neutrophils 4%

Blasts 17%

Hemoglobin (Hgb) 10.4 g/dL (104 g/L)

Hematocrit (Hct) 28.7%

Platelets 49,000/mm3 (49 x 109/L)

1. Interpret C.O.’s CBC results. What does the presence of blasts in the differential mean?

2. What was the purpose of the bone marrow biopsy?

3. What nursing care is provided immediately post bone marrow biopsy?

4. Considering all the admission data, what potential problem will you be alert for when C.O. returns to the unit after the catheter insertion?

5. What assessments about the central catheter are essential for you to perform?

CASE STUDY PROGRESS

On the ninth day of continuous infusion of chemotherapy, the UAP reports C.O.’s vital signs to you.

Vital Signs

BP 110/54 mm Hg

Heart rate 115 beats/min

Respiratory rate 26 breaths/min

Temperature 101.6° F (38.7° C)

6. What other assessments should you make right now and why?

CASE STUDY PROGRESS

Your assessment findings are unremarkable and you notify the intern on call of C.O.’s vital signs. After evaluating C.O., the orders shown in the chart are written.

Physician’s Orders

Blood cultures now × 2 sites

CBC with differential now

Acetaminophen suppository 650 mg q4-6h prn

Imipenem/cilastatin sodium 500 mg IV piggyback q8h

Notify hematologist for temp over 100.0° F (37.8° C)

7. Do these orders seem appropriate? Explain.

8. What will your next action be?

Laboratory Test Values

WBCs 1200/mm3 (1.2 x 109/L)

Monocytes 25%

Lymphocytes 65%

Neutrophils 5%

Blasts 5%

Bands 0%

Hgb 6.8 g/dL (68 g/L)

Hct 21.3%

Platelets 17,000/mm3 (17 x 109/L)

9. What do these laboratory values indicate about her immune system?

10. Considering the previous data, what blood products will most likely be given to C.O.?

CASE STUDY PROGRESS

With continued blood product support and antibiotic coverage, C.O. is able to complete 14 days of therapy and a bone marrow biopsy shows she is in complete remission. HLA typing has been done on all her siblings. Her oldest brother is a perfect HLA match and has agreed to donate bone marrow. C.O. is being discharged with plans to readmit her to the bone marrow transplant unit within the next few weeks.

11. What does “complete remission” mean for C.O., and what effect did it have on the decision to perform a bone marrow transplant?

12. What type of bone marrow transplant will she have? Briefly describe this transplant process.

13. Name 4 priority problems C.O. will face in undergoing a bone marrow transplant. Put a star next to the most important priority

14. What is the most important intervention post-transplant?

A. Giving analgesics for postprocedural pain

B. Monitoring for signs of infection and bleeding

C. Weighing her daily and offering small, frequent meals

D. Offering emotional support to C.O. and her family during recovery

15. What type of isolation will C.O. need? Outline the guidelines for maintaining this type of isolation.

16. Undergoing a bone marrow transplant is challenging. Describe how you would provide emotional support to C.O. and her family.

17. Name 3 complications C.O. will be at risk for after the transplant.

18. Describe graft-versus-host disease.

19. True or false. If the transplanted cells do not engraft, C.O. will die unless another transplant is tried and successful. Defend your response.

Answer 1

Complete blood count is a test done in order to assess to assess the amount of cell that circulate in blood this may include red blood cells , white blood cells and platelet and may be help to evaluate the presence of any disease.

The nomal

Hemoglobin levels is 13-18g/dl as stated the value above which is 10.4 which states the patient is anemic.

Hematocrit- The normal Hematocrit level 40-54% as stated above it is 28.7% which is low which may be a sign of anemia.

Platelet count should be 150-400 lac where as in the above data time is 49000 which means the patient has thrombocytopenia along with raised monocytes, reduced lymphocytesand neutrophils.

An increase in monocyte level may indicate presence of infections.

Blast cells may indicate the presence of abnormal cells. Which may help diagnose acute myeloblastic leukemia.

2) purpose if bone marrow biopsy-

May help determine any abnormality in the blood cell production.

May help identify the cause for thrombocytopenia, leucopenia, polycythemia.

Help assess the presence of genetic abnormalities.

Rule out acute Lymphoblastic leukemia and myeloblastic leukemia.

To assess for fever of unknown origin.

3) nursing care-

Provide complete sterilized environment

Prevent spread of infection.

Provide sterile diet.

Check for fever

Watch for hematoma.

Admit patient in blood marrow unit.

Prevent infections.

Strict aseptic techniques.

Sterilization of all products.

Prophylactic antibiotics should be provided.

Assess and trace blood report.

Close monitoring.

4)

After catheterization

Promote infection free environment.

Assess for signs of catheter associated infection.

Promote catheter care.

Use strict aseptic techniques while insertion

Empty urine bag every hour.

Prevent back flow by keeping below waist.

Provide prophylactic antibiotics.