INTENSIVE NURSING PRACTICUM - Pediatric Ward (BMC)

CASE STUDY 5: Pediatric Oncology

1. Personal Data of Patient

The subject of this case study is given the name patient ALL to protect his real
identity. She is a 12 years old, female, born on the 19 th of July year 2005 in Marcelo
General Hospital Baliuag. A Filipino citizen, baptized as a Christian Methodist, and a
resident of Sulivan, Baliuag, Bulacan. She was admitted in Lung Center of the
Philippines, last June 26, 2017 with chief complaints of epistaxis, gum bleeding and
low red blood cell and platelet count.

The patient ALL family is a nuclear type of family composing of three members;
her mother, father and patient ALL herself. Her father and mother are both 38 years
of age. Her father formerly works as a security guard at a firm in Manila and is
currently working in factory. Her mother on the other hand is a plain housewife. Mr.
and Mrs. are married and have been living together for 14 years.

2. Present and Past Illnesses

2.1. History of Present Illness. Year 2007, at the age of 3, she was diagnosed of
having acute lymphocytic leukemia. It was started with on and off fever,
cough and colds, shortness of breath, joint pain, and muscle weakness for
almost 1 week. They seek medical attention after a week, intervention was
given for fever and pain, laboratory test was done like urinalysis, chest x-ray
AP/LAT, and complete blood count. CBC results shows very low RBC and
Hemoglobin, low platelets and slightly elevated WBC specifically
Lymphocytes. During follow up check-up, her doctor said that the child is
having leukemia. They are reffered to pediatric hematologist at Candaba,
Pampanga. Same as general pediatrician, after several confirmatory test like
peripheral blood smear and repeat complete blood counts, pediatric
hematologist confirmed that the child is having acute lymphocytic leukemia.
According to the mother, the doctor said that it is curable but they need to
spend million to treat the disease. After confirming if the child is really having
the disease, pediatric hematologist referred the patient to University of Sto.

A Case Study of Pediatric Patient with Acute Lymphoblastic Leukemia (L1) 1

 Tomas Hospital to undergo several tests to determine what type of
lymphoblastic leukemia she have. Lumbar puncture, Bone marrow biopsy,
Chest X-ray, CSF analysis and CT-scan was done. After a series of test, the
patient was finally diagnosed of having acute lymphocytic leukemia (L1),
without CNS involvement and metastasis.
Her pediatrician in University of Santo Tomas Hospital referred the patient
in pediatric hematologist and oncologist at Fe del Mundo Medical Center for
chemotherapy. To treat her condition several medical management was done
it includes chemotherapy every month, blood test twice a month, lumbar
puncture every to 2 months and bone marrow biopsy every 3 months. After 3
years of treatment the pediatrician declared that the child is cancer free,
however, she needs to have follow up check up every 3 months with her
complete blood count result.
After a year, year 2011 during her follow up, the pediatrician diagnosed
the child is having a relapsed ALL. A series of diagnostic tests was done to
check the extend of the disease, to evaluate CNS involvement and
metastasis. Luckily no CNS involvement, leukemic cells stays in bone marrow
and no metastasis. Another cycle of chemotherapy and blood transfusion was
done to treat the disease. She completed the treatment for 3 years and she
was declared as cancer free again.

Year 2016, February,another relapsed of acute lymphocytic leukemia and

she was referred to Lung center of the Philippines for management. She was
confined last Feb. 20, 2016 due to fever, neutropenia, thrombocytopenia and
anema, with chief complaint of body weakness and headache. Series of
diagnostic tests was done, to evaluate the extent of the disease process. As
initial test lumbar puncture was done to analyze the CSF for invasion of
leukemic cells, result shows no CNS involvement. Bone marrow biopsy was
also done to investigate the extent and what type of ALL, test result reveals
L1 type of ALL. Transfusion of 2 units PRBC and 2 units of platelet
concentrates was done as initial intervention. Chemotherapy was started after
one week of confinement. Year 2017, her current chemotherapeutic
medications are the following, Cyclophosphorine, Doxorubicin and Vincristine
once a month as IV meds, L- asparaginase thru IM once a month,
A Case Study of Pediatric Patient with Acute Lymphoblastic Leukemia (L1) 2
 Methotrexate IT once a month and orally twice a week, Dexamethasone oral
once a day for 4 days after IV meds and Metoclopramide IV after IV
chemotherapy meds. Monthly she undergo blood tests, it includes complete
blood count, liver profile, reticulocyte count and other chemistry test. Lumbar
puncture for CFS analysis was done every 2 months. Every 3 months bone
marrow biopsy was perform to check the response of leukemic cell to
chemotherapy. Monthly she undergo chemotherapy at Lung Center of the
Philippines, currently she is on intensification phase of treatment, however
before chemotherapy several blood tests like CBC, Bilirubin, SGOT/SGPT,
Blood Uric Acid and reticulocyte count was done at Hi-Precision Diagnostics.
June 28, 2017, she had undergone chemotherapy. 12:00pm, June 29, 2017,
she underwent blood test, during that time she is pale and weak in
appearance, and she is crying and moaning that time. In phlebotomy area,
she was very afraid, with lack of control, cooperation, when you hold her arm
for vein assessment she almost cry and withdraw her arm. “Mommy ayaw ko
na po ng injections masakit nanaman po iyan, marami nanamang tusok
kamuka nung dati” as verbalized by the client. June 29, 2017 at around 5pm,
was her last confinement in Lung Center of the Philippines, with chief
complaints of epistaxis, gum bleeding, low red blood cell and platelet count
and bone pain. July 28, 2017 was her last chemotherapy in Lung Center of
the Philippines.

2.2. Family History. According to the mother of patient, on the father side of the
patient they had history of aplastic anemia. While on the mother side history
of diabetes, hypertension and cardiovascular diseases was mentioned.
Familial history of breast and ovarian cancer on her mother side.

2.3. Past Illness. The mother states that, the patient experienced measles and
chicken pox when she was 2 years old. The mother can’t recall the exact date
of the occurrence of disease and how long it occurred. The patient
experienced pneumonia when she was 1yr old and 3mos. More often she
experiences cough and colds. No known allergies for any medications and
foods.

A Case Study of Pediatric Patient with Acute Lymphoblastic Leukemia (L1) 3

3. Reaction & Expectation to Illness/Hospitalization. For almost 10 years of fighting
for her life, the child accept her condition, “ may reason po siguro si God kung bakit
po ako nagkaroon ng ganitong sakit” as verbalized by the patient. According to her
mother, what ever happens she will always be their to tke care her child, “kahit na
maubos yung pahanon ko para lang alagaan siya hindi ako magsasawa, basta
mabigay ko lng ung best ko para sa anak ko” as verbalized by the mother. We are
blessed actually, many people offered financial support to my daughter, and others
gave small things or gifts just to make her happy. “Kung ano po yung kaloob ni God
para sa kalusugan ng anak ko tatanggapin ko basta po patuloy ko parin siya
ilalaban”as verbalized by the mother. Her statement about the condition of her
daughter shows courage and trust to God. During interview, though I almost cry
while listening to her story, the mother never show weakness, she shows optimism
and courage that one day her daughter will be totally cure and cancer free.

4. Activities of Daily Living

4.1. Circulation. Her pulse rate was 98 beats per minute. Her lips are pale in
color as well as her palpebral conjunctivas. She has palmar pallor. Nail beds
are pale and capillary refill time is 3 sec. Her bleeding time result was 15mins
and 30sec. using ivy’s method. Her body temperature is 37.3 degrees
Celsius. Her Blood pressure was 90/60mmHg.

4.2. Respiration. She experiences difficulty in breathing after certain activities for
a short period of time. She felt tired easily that’s why she seldom plays with
her friends. During interview, her respiratory rate was 20 breaths per minute.

4.3. Food/Fluid. The informant states that, the patient eats three to four times
daily, which includes breakfast, lunch, merienda, and dinner. Usually she can
consume 1-2 cups of rice and 1-2 cups of viand. The usual content of her
viands are fish, meat and vegetables. Patient’s favorite food was mixed
vegetables and sinigang. Her mother is the one who prepare and cook her
food. As stated by the mother, she makes sure that the foods that the patient
will eat are well cooked and she avoids serving raw foods. They seldom go to
mall to eat fast-food. They used to eat “lutong bahay” than those foods that

A Case Study of Pediatric Patient with Acute Lymphoblastic Leukemia (L1) 4

 are prepared outside. In terms of fluid intake, she can consume 1.5 L to 2 L of
fluid. She loves drinking milk, usually she can consumed 2 glass per day. She
seldom drinks soft drinks and coffee.

4.4. Personal Hygiene. According to the mother, her daughter takes a bath once
a day. She brushes his teeth 2 to 3 times a day. She used ethyl alcohol to
sanitize her hand. She used hypoallergenic shampoo and soap in bathing to
avoid skin and scalp allergy. She used to change her clothes 3 to 4 times a
day. She visits her dentist once or twice a year for dental hygiene. She cleans
her ears twice a week assisted by her mother. She used to cut her nails once
or twice a week. She avoids using any form of deodorant and perfume. As per
mother, the patient cleans her body before she sleep.

4.5. Rest/Sleep. The client sleeps at around 9pm and wakes up at 7am. No rituals
to fall sleep. She takes a nap at around 1pm until 2pm. She watches
television and browsed the net during rest time. When she feels tired she
takes a rest.

4.6. Usual Pain/Discomfort. Usually she experiences joint pain and with doctors
advised she takes analgesic to relieve the pain. When she takes
dexamethasone she experiences muscle pain. Usually she has mouth sore
and gum bleeding.

5. Competencies
5.1. Physical. When you look at her, she looks pale, no hair and nails are
hyperpigmented due to disease process and side effect of cytotoxic. The
patient can perform activities of daily living with minimal help of her mother.
But she feels so tired after performing some activities. When she feels bone
pain she needs assistance from her mother or father to walk and go to
comfort room.

5.2. Emotional. The patient is a jolly person. She can easily appreciate things in
life even a small gift, she gives importance to it. Hello kitty items make her

A Case Study of Pediatric Patient with Acute Lymphoblastic Leukemia (L1) 5

 happy. One thing that she really hate and afraid with are needles that why
she always cry during blood extraction and other invasive procedure that
involves needle insertion.

5.3. Mental. The client can maintain eye contact during interview. She can recall
past events in her life. She can read and write even though she didn’t
experience to go in school but her mother tried her best to teach the patient.
Her mind was so creative in terms of doing art works.

5.4. Spiritual. The patient used to go in their Methodist church every Sunday with
her mother and father. She sings worship songs to give praise to our God. “
napaka bait ni God sa amin kahit ilang ulet na bumalik yung leukemia niya
marami parin tumutulong sa amin” as verbalized by the mother. They said
that they will never fail to praise God for all the blessings and guidance. The
mother also believes that God has a good plan for their family.

5.5. Social. She seldom goes out of their house to play with her friends because
she feels so tired when she plays too much. Aside from that she is very shy
because of hair loss and she thinks that she’s different from the other child.
One of the reason why she seldom goes out of their house is she believes
that there is a risk of acquiring infection from her playmate. However, every
chemotherapy session she used to play with other cancer patients.

5.6. Environmental. Her father is a smoker. Patient’s house is well lighted and
ventilated. There is comfort room inside. Things inside are arranged in proper
position.

6. Physical Assessment
6.1. General Appearance. The patient is weak and pale in appearance. She is
wearing pink shirt and pink pants. She seating on phlebotomy table during
physical assessment. The patient is unable to walk during that time due to
bone pain. She is conscious, coherent and cooperative during examination.

A Case Study of Pediatric Patient with Acute Lymphoblastic Leukemia (L1) 6

 6.2. Vital Signs
6.2.1. Blood Pressure – 90/60 mmHg
6.2.2. Temperature -37.3 degree Celsius
6.2.3. Pulse Rate- 98 beats per min.
6.2.4. Respiratory Rate- 20 breaths per min.

6.3. Physical Assessment

6.3.1. Head. The size of the head is proportionate to the body. Upon
inspection and palpation, no lesion, scars and masses. Her scalp is
clean. She has no hair as side effect of chemotherapy. She is using
bonnet to protect and cover her scalp from sunlight.
Her face is round in appearance. It has an intact skin and pale in
color. Her skin is soft to touch. Her facial feature is symmetric. She has
very thin eyelashes and eyebrows.
Her eyes are symmetrically aligned with each other. It is round in
appearance and she has eye bags. The pupil is equally round and
reactive to light and accommodation. Her sclera is white in color. Her
palpebral conjunctive is pale in color. There are no discharges present.
Upon assessment, she blinks 20 times per minute but it varies. The
eye meets completely when he closed it.
Her ears are proportionate to the face; both symmetrically aligned
to the outer canthus of his eyes. There is minimal dirt present in ear.
The color of the skin is same to facial color. The pinna recoils after
being folded. The patient can distinguish sounds even in minimal or
loud voice.
Her nose is symmetrically aligned in the midline and proportion to
the other facial features, there is no lesions, deformities, inflammation
and discharges. She can distinguish different types of odor.
Her lips is dry and pale in appearance. The gum is pale and may
bleeding during examination. She has a complete set of teeth. She has
halitosis. Teeth is slightly white in appearance. She has no dental
caries. Some oral lesions seen upon examination. The tongue is

A Case Study of Pediatric Patient with Acute Lymphoblastic Leukemia (L1) 7

 symmetrically aligned, however upon examination some lesions was
noted.

6.3.2. Neck. It is proportionate to the body. She can move her head up and
down, side by side. Her trachea moves as she swallows and it is
symmetrically aligned to the neck. Her thyroid gland is palpable.
Carotid vein is also palpable. There are swollen lymph nodes upon
palpation.

6.3.3. Chest. Her clavicle is visible. She has an intact skin. It is proportionate
to the body. There is no nodule, scars or masses upon palapation. Her
skin on axilla is also intact. Breast is symmetrical to each other. Her
respiratory rate is 20 per minute while upon auscultation of the chest
cadiac rate is 95 beats per minute. She has no abnormal breath sound
and no difficulty upon breathing.

6.3.4. Back. Her skin is intact and has no pimples, scars or lesions. No
abnormal sound heard upon auscultation.

6.3.5. Abdomen. The stomach is uniformed in color, the skin is slightly dry.
No lesion upon examination. During palpation no masses or swelling
present. Hyperactive bowel sounds characterized by gurgling sound
upon auscultation for about 5 minutes.
6.3.6. Extremities
6.3.6.1. Upper Extremities. Her arms are symmetrical in length with
intact skin. She can move her right and left arm without pain. Her
hands are able to conduct adduction and abduction slowly due to pain
upon movement. With some buirses seen upon examination.
Hematoma seen in brachial area as a result of multiple extraction. Her
nail beds are pale and capillary refill time is 3 sec. palmar pallor is
seen. With some lesion and bruises of skin at dorsum area of the hand
as a result of multiple intravenous insertion and administration of
cytotoxic drugs. Skin is warm to touch bilaterally from fingertips to

A Case Study of Pediatric Patient with Acute Lymphoblastic Leukemia (L1) 8

 upper arm. Radial pulses have equal strength bilaterally. Brachial
pulses have equal strength bilaterally.
6.3.6.2. Lower Extremities. Skin is pale in appearance. Legs are
free of lesions or ulcerations. Identical size and bilaterally no swelling
or atrophy. No edema present in the legs. Toes, feet, and legs are
equally warm bilaterally. Femoral pulses strong and equal bilaterally.
Veins are flat and barely seen under the surface of the skin. She can
move her right and left lower extremities without pain.
Activities:
1. Make your own disease study related to ALL with pathophysiology in diagram format
2. Formulate a nursing care plan related to the case (actual/potential)
3. Formulate a drug study related to the case (minimum of 2 anti-neoplastic drugs)
4. Look for a journal related to the case (e.g., related to pediatric chemotherapy, blood
transfusion or bone marrow aspiration/biopsy)

Prepared by:

Mark Joseph V. Liwanag, RN, MSN

Clinical Instructor – Pediatric Ward (BMC)

A Case Study of Pediatric Patient with Acute Lymphoblastic Leukemia (L1) 9

Table 2: CBC and Reticulocyte count results from April 20, 2017 to June 29, 2017

TEST 06/27/17 05/24/17 04/20/17

(NORMAL RANGE) 12:30PM 11:53AM 10:53AM

HEMATOLOGY

Reticulocyte cnt. ↑ 2.10 0.50 ↑ 2.60

(0.5-1.5%)

CBC W/ PLT.

RBC ↓ 2.54 ↓ 3.45 ↓ 3.03

(3.93-5.22 x 10^12/L)

Hemoglobin ↓ 85.00 106.00 ↓ 95.00

(100.00-150.00 g/L)

Hematocrit ↓ 0.25 ↓ 0.31 ↓ 0.28

(0.34-0.42 vol. frac.)

Platelets ↓ 70.00 ↓ 106.00 ↓ 81.00

(150.00-450.00 x 10^9/L)

WBC ↓ 1.83 4.00 4.38

(4.00-10.50x10^9/L)

A Case Study of Pediatric Patient with Acute Lymphoblastic Leukemia (L1) 10

Table 3: Differential count results from April 20, 2017 to June 29, 2017

TEST 06/29/17 05/24/17 04/20/17

(NORMAL RANGE) 12:30PM 11:53AM 10:53AM

DIFFERENTIAL COUNT

Neutrophils 65.10% ↑ 85.70% 75.60%

(18.00-77.00%)

Lymphocytes 22.50% ↓ 10.30% ↓ 12.30%

(17.00-55.00%)

Monocytes 6.20% 2.50% ↓ 1.80%

(2.00-13.00%)

Eosinophils 5.60% 1.50% ↓ 10.30%

(0.00-7.00%)
A Case Study of Pediatric Patient with Acute Lymphoblastic Leukemia (L1) 11
Basophils 0.60% 0.00% 0.00%
(0.00-1.00%)
 TEST
06/29/17 05/24/17 04/20/17
(Normal
12:30PM 11:53AM 10:35AM
Range)
CHEMISTRY
SGPT/ALT
10.00-35.00 ↑ 309.59 ↑ 110.45 ↑ 83.49
U/L

Table 4: SGPT results from April 20, 2017 to June 29, 2017

TEST 06/29/17 04/20/17

(Normal Range) 12:30PM 10:35PM
Indirect Bilirubin 15.80 5.00
(1.71-17.10 umol/L)
Direct Bilirubin ↑ 7.10 2.50
(0.00-5.30 umol/L)
Total Bilirubin ↑ 22.90 7.50
(1.71-20.52 umol/L)

Table 5: Bilirubin results from April 20, 2017 and June 29, 2017

A Case Study of Pediatric Patient with Acute Lymphoblastic Leukemia (L1) 12