CHRONIC

LYMPHOCYTIC
LEUKEMIA
Grand Case Presentation
March 19, 2010
• GENERAL OBJECTIVES:
 
• After 2 hours of lecture-
demonstration, the BSN III
students will be able to acquire
basic knowledge, develop skills,
and attitude in understanding the
concept of Chronic Lymphocytic
Leukemia..
 Chronic Lymphocytic Leukemia
(CLL)
 Results from an inherited injury to the DNA
of a single cell, a lymphocyte, in the bone
marrow.

The result of this injury is the uncontrolled

growth of lymphocytic cells in the marrow
leading invariably to an increase in the
number of lymphocytes in the blood.
MANY CASES OF C.L.L. ARE
DETECTED BY:

 Routine blood tests

 Enlarged lymph nodes
 Enlarged liver and spleen
 Fatigue
 Bone pain
 Excessive sweating
 Loss of appetite
 Weight loss
 Flank pain
 Generalized itching
 Abnormal bruising (a more well
known symptom)
 Types
of
Leukemia
 Acute Leukemia Chronic Leukemia
- bone marrow cells - the cells can
cannot mature mature partly
properly but not
- immature completely
leukemia cells - cells may look
continue to fairly normal,
reproduce and but they are not.
build up.
Myeloid Leukemia
 start in early forms of
myeloid cells
a. white blood cells (other than lymphoblastic leukemia).
lymphocytes),
b. red blood cells, or
c. platelet-making cells
(megakaryocytes)
are myeloid leukemias (also
known as myelocytic,
myelogenous, or non-
lymphocytic leukemias).
Lymphocytic
Leukemia
starts in lymphocytes
also known as lymphoid or
Lymphomas are also cancers
that start in lymphocytes. But
whereas lymphocytic
leukemias develop from cells
in the bone marrow,
lymphomas develop from cells
in lymph nodes or other
organs.
Risk Factors
 Certain chemical
exposures
- some studies have linked exposure to
Agent Orange, an herbicide used during the
Vietnam War
- other studies have suggested that
farming and long term exposure to some
pesticides
 Family history
- First-degree relatives (parents, siblings,
or children) of CLL patients have a 2- to 4-fold
increased risk for this cancer

 Gender

- CLL is slightly more common in males

than females
Race/ethnicity
- CLL is more common in North America
and Europe than in Asia.

- In the Philippines there are 2,596 cases

out of 86,241,697 people
RELATED TERMS

Antibodies

- Proteins that are made by B

lymphocytes in response to foreign
substances called antigens
Mutation

- An alteration in a gene that results from a

change (injury) to the DNA in a cell

Oncogene

- A mutated gene that is the cause of a cancer

Pancytopenia

- A decrease below normal in

the number of the three major blood
cell types: red cells, white cells, and
platelets.
 The
Patient’s
Profile
Name: Mr. L. T. S.
Age: 67 years old
Date of Birth: January 20, 1942
Sex: Male
Civil Status: Married
Nationality: Filipino
Religion: Iglesia Ni Cristo
Occupation: Master cutter
Place of Birth: Cebu City, Cebu
Address: Corner 1, Tabura St., Pob.,
Pardo, Cebu City, 6000
Date of Admission: January 19, 2010 @ 2:01 pm
Date of Discharge: January 23, 2010
Attending Physician: Dr. Leilani Yee - Cabahug
Hospital Department: Chong Hua Hospital
Case No.: 05-002-228-57-81
How was patient brought: Ambulatory
Who accompanied the patient: Granddaughter
Admitting complaint: pallor, weakness,
dyspneic on
exertion and blood
transfusion
Admitting diagnosis: anemia,
pancytopenia
Final Diagnosis:
Chronic Lymphocytic Leukemia
History of the
Present Illness
 A case of patient L. T. S. , 67 yrs.
Old, Filipino, married, an Iglesia Ni
Cristo and a resident of Corner 1,
Tabura St., Pob., Pardo, Cebu City,
6000 was admitted to Chong Hua
Hospital last January 19, 2010 at
2:01 pm with chief complaint of
dyspnea and fatigability.
 Five months prior to admission,
patient verbalized difficulty in
breathing on moderate exertion with
easy fatigability and pellet like stools.
He sought consultation from a near
clinic in Pardo. Complete Blood Count
revealed Pancytopenia. Patient was
then advised admission but refused.
 Three months prior to admission,
patient had an onset of easy fatigability
and noted pallor. Patient sought consult
to Chong Hua Hospital, CBC showed
hemoglobin of 6 mg/dL thus he was
advised for blood transfusion of 3 units
of RBC. Patient had underwent a bone
marrow biopsy that showed
hypercellular marrow with a typical
lymphoid proliferation but he was then
discharged with improved disposition.
 One week prior to admission,
there was again recurrence of easy
fatigability that prompted patient to
sought admission again for
another .needed blood transfusion.
 PAST
MEDICAL
HISTORY
 Patient L.T.S. claimed that he didn’t
received complete childhood
immunizations. Whenever he feels sick he
would resort to self-medication and
sometimes consult his significant others
for medication. He had no known food
and drug allergies. Reported that
hypertension and cancer as her heredo-
familial disease. Patient had no previous
hospitalization, is hypertensive, non-
diabetic. He does not smoke nor drink or
alcoholic beverages.
 Nursing
Review of
Systems
Health perception- Health Management
-For the patient, being healthy is important. That
is when a person is strong and capable to do his daily
activities.
-When the patient feels discomfort in his body, he
usually goes to the “manghihilot” before consulting a
doctor. When his condition worsen, then this would be
the time where he seeks for health care.
-The patient usually goes for herbal medicines
whenever he experiences minor health problems.
- during hospitalization, the patient was eager to
seek health care from medical practitioner.
Nutritional Metabolic Pattern

- He barely eats meat rather he loves

eating vegetables.
- He eats 3x a day and drinks water 5x a
day
-During his hospitalization, he was on diet
as tolerated regimen and eventually eats the
food given to him.
Elimination
- The patient defecates twice a week.
According to him, the characteristic of his stool is
pellet like.

- He urinates 7x a day and does sometimes

feel pain and difficulty.

- during hospitalization, patients was

monitored and recorded and revealed he deficated
4x a week and also urinated 4x a day with no
difficulty.
Activity and Exercise
-The typical activity of the patient usually
comprises of reading newspaper.
-Before he was admitted, he had been active in
his work as a tailor but when he was diagnosed,
he preferred to be engaged only on doing
household chores but unfortunately, he become
easily tired and opted to just rest and watch
television.
- during hospitalization, he was advised to follow a
complete bed rest regimen.
Cognitive-perceptual Pattern

- Patient is coherent and is able to

communicate effectively. He talks in a moderate
pace with words spoken well.
Sleep and Rest Pattern
-6 months before admission, patient had
already been experiencing intermittent
sleep disturbance because of difficulty in
breathing.
-The patient sleeps at 8 pm and wakes
up in 1 am and eventually takes a nap
usually during 8am to 11 am.
- during hospitalization, patient had a
regular sleep pattern. Usually he sleeps
at 9 pm and wakes at 6 am.
Self-perception

-The patient had an inner feeling that there is

something wrong in his health.
- He views himself as a simple person.
-during hospitalization, he has a great
confidence towards his health care providers
and was very optimistic that his health status
will improve.
Role-relationship

- The patient has a harmonious relationship

with his family and friends.
-Though he is a quite person, he still
possessed a good sense of humor which
according to him, made him an enemy-free
person.
- during hospitalization, he has a very good
relationship towards the his health care
providers.
Sexuality-reproductive

-The patient is no longer sexually active

because according to him, he is too old for the
activity.
- Before when he was still active, he usually
uses condom as a protection.
Coping-stress

-Whenever the patient has a problem, he

primarily asks for the guidance of the Lord. He
then shares his problem to his friends and asked
for an advice.
-He also reads newspaper as a diversional
activity.
- during hospitalization, pt. watches Television as
recreational activity.
Value-belief

- The patient is an Iglesia Ni Cristo

believer.

- He always asks for Lord’s guidance and

reads the bible.
 Physical
Assessment
GENERAL SURVEY
Received patient lying on bed, conscious,
responsive, coherent, afebrile, in respiratory
distress, body weakness and pallor noted. With
ongoing IVF of PNSS 500ml @ 100ml/hr infusing
well at left arm.

Vital Signs
Height and Weight
• BP = 150/90 mmHg • Height = 5 ft. 7 in.
• HR = 85 bpm • Weight = 152 kg
• RR = 30 cpm
• T = 36.8 ºC
 SKIN
• Brown skin complexion and minimal
pigmentation in sun-exposed areas.
Pallor was noted and skin was cold
to touch. It is dry and slightly rough
in texture. Has senile skin turgor. No
bleeding, ecchymoses, lesions,
bruises, and masses noted.
 NAILS

Nail plates on both fingernails and

toenails are slightly pale. With
concave curvatures and brittle
edges. Poor capillary refill of
more than 2 seconds observed
upon blanch testing.
 HEAD
Head is normocephalic and
symmetrical with frontal, parietal, and
occipital prominences. Gray hair is
minimal, unevenly distributed with no
infestations noted. Smooth skull
contour with uniform consistency
without nodules and masses noted
upon palpation.
 Eyes and Conjunctiva
Eyebrow hairs are evenly distributed
symmetrically aligned with equal movement
upon raising and lowering. Eyelashes equally
distributed. Skin of both eyelids is intact, closes
symmetrical with no discharge and
discoloration. Pale conjunctiva. Cornea in both
eyes is cloudy with slow blinking reflex. Pupils
are black in color, flat, equally round but with
sluggish reaction to light accommodation. Both
eyes are coordinated with each other with
20/100 vision.
 EARS
Auricles have same color as facial
skin. Both are symmetrical and
aligned with outer canthus of eyes,
firm and not tender. Pinna recoil
after it is folded. Normal voice tones
are slightly not audible to the
patient. Both ears are not able to
hear the ticking of a watch.
 NOSE
• Symmetrical and located at
midline, without discharges, no
lesions, and masses noted upon
palpation. Flaring of the nose
noted. Air moves freely as the
client breathes through the nares.
The mucosa is pale. Sinuses are not
tender upon palpation.
 MOUTH
Outer part of the lips are symmetrical,
purplish in color, dry, cracked and are able to
purse. Pale and firm gums without retraction
noted. Tongue is in central position, dry,
slightly rough with thin whitish coating
without lesions assessed. Tongue moves
freely without tenderness, without palpable
nodules noted with uvula in the midline.
With poor gag reflex.
 NECK
Neck is located at midline. Can able to
perform coordinated movements without
discomfort with minimal strength on both
sternoclaidomastoid and trapezius muscles.
Lymph nodes are not palpable. Trachea is
the midline of neck and spaces are equal on
both sides. Thyroid gland is not visible upon
inspection without bruit sounds heard upon
auscultation.
 ANTERIOR THORAX

Anterior thorax is symmetrical. Skin

is uniform in color. No lesions,
masses, tenderness and redness
noted. No crackles sound on
auscultation. The respiratory rate
was 30 cycles per minute, with the
Use of accessory muscles noted.
 POSTERIOR THORAX
Posterior thorax is symmetrical.
Spine is vertically aligned. No
lesions, masses, tenderness, and
redness noted. No crackles
heard during respiration.
 HEART
Point of maximum impulse is heard over left
midclavicular line and near 5th left intercostals
space which is slightly below the nipple with a rate
of 80 beats per minute, with S1 and S2 sounds
heard upon auscultation. Carotid arteries have full,
thrusting pulsations with quality remaining the
same when client breathes, turns head or changes
position. With no bruit sounds noted. Jugular veins
are not visible or distended. Weak pulsation noted
in lower extremities.
 BREAST AND AXILLAE
Breasts are rounded and are slightly
unequal in size with skin uniform in color,
smooth and intact. Areolas are both round
and bilaterally the same and brownish in
color. Nipples are round, and equal in size
with brownish color. No discharges noted.
Both axillae have minimal axillary hairs and
are slightly darker in color. Breasts and
axillae do not have tenderness, masses or
nodules.
 ABDOMEN
Blemished or pigmented skin is noted
in the abdominal area that is uniform
in color. It is flabby, distended and
round in contour. Audible
borborygmi sounds heard upon
auscultation about 11 bowel sounds
per minute.
 EXTREMITIES
AND
MUSCULOSKELETAL
FUNCTION
 UPPER EXTREMITIES
Both arms are symmetrical in shape and
in size. Reduction of muscle size as
evidenced by appearance of thin flabby
muscles. Arms are moving coordinately
but with limited range of motion when
complying his daily routines. No
deformities and tenderness of bones.
Absence of crepitations and palpable
nodules
 LOWER EXTREMITIES
Symmetrical on both sides of the body
with no contractures and absence of
tremors . Reduction of muscle size.
Bones have no deformities, no
tenderness, nodules nor crepitations
noted. Scar is noted on the anterior
lower half of the left lower extremity
about 2 inches in diameter.
 NEUROLOGIC SYSTEM

Mental Status:
Awake, conscious, responsive and
coherent. Facial expression is symmetrical and
appropriate to the content of the conversation.
 
Sensory Assessment:
Can feel cold or warm, can identify
shape drawn on the skin
 
Motor Assessment:
Atrophy of the muscle noted, decrease
muscle tone and muscle strength observed.
LABORATOR
Y RESULTS
 Complete Blood Count
11/19/09
HEMATOLOGY NORMAL VALUES RESULT

PLATELET 0.15 - 0.40 x 105 / mL 0.08 x 105 / mL

HEMOGLOBIN 14-18 mg/dl 6 mg/dL

HEMATOCRIT 0.40 – 0.54% 0.32%

RED BLOOD CELL 4.5 – 6.0 x 1012L 4.0 x 1012L

WHITE BLOOD CELL 5.0 – 10 x 109L 3.5 x 109L

 Complete Blood Count
11/21/09
HEMATOLOGY NORMAL VALUES RESULT

PLATELET 0.15 - 0.40 x 105 / mL 0.20 x 105 / mL

HEMOGLOBIN 14-18 g/dl 15 g/dL

HEMATOCRIT 0.40 – 0.54% 0.45%

RED BLOOD CELL 4.5 – 6.0 x 1012L 4.8 x 1012L

WHITE BLOOD CELL 5.0 – 10 x 109L 6 .3x 109L

 Complete Blood Count
11/22/09
HEMATOLOGY NORMAL VALUES RESULT

PLATELET 0.15 - 0.40 x 105 / mL 0.25 x 105 / mL

HEMOGLOBIN 14-18 g/dl 16 g/dL

HEMATOCRIT 0.40 – 0.54% 0.42%

RED BLOOD CELL 4.5 – 6.0 x 1012L 5.6 x 1012L

WHITE BLOOD CELL 5.0 – 10 x 109L 7.1 x 109L

 Complete Blood Count
01/19/10
HEMATOLOGY NORMAL VALUES RESULT

PLATELET 0.15 - 0.40 x 105 / mL 0.35 x 105 / mL

HEMOGLOBIN 14-18 g/dl 15 g/dL

HEMATOCRIT 0.40 – 0.54% 0.46%

RED BLOOD CELL 4.5 – 6.0 x 1012L 5.2 x 1012L

WHITE BLOOD CELL 5.0 – 10 x 109L 8.0 x 109L

 Complete Blood Count
01/22/10
HEMATOLOGY NORMAL VALUES RESULT

PLATELET 0.15 - 0.40 x 105 / mL 0.34 x 105 / mL

HEMOGLOBIN 14-18 g/dl 17 g/dL

HEMATOCRIT 0.40 – 0.54% 0.50%

RED BLOOD CELL 4.5 – 6.0 x 1012L 4.9 x 1012L

WHITE BLOOD CELL 5.0 – 10 x 109L 6.8 x 109L

 BONE MARROW BIOPSY REPORT
11/19/09
INTERPRETATION
- bone marrow showed hypercellular marrow with a typical lymphoid
proliferation.
WHITE BLOOD CELL 5.0 – 10 x 109L 3.5 x 109L

DIFFERENTIAL COUNT

NEUTROPHILS (segmenters) 0.38 – 0.68 27.5

LYMPHOCYTES 0.22 – 0.53 3.80

EOSINOPHILS 0.01 - 0.07 0.05

MONOCYTES 0.05 - 0.12 0.09

BASOPHILS 0.002 - 0.01 0.006

 ULTRASOUND
11/20/09
IMPRESSION: Mild Spleenomegaly.
Relative increase in liver parenchyma echogenecity w/c
may relate to normal variance (40 %) or early non
specific medical blood disease (60%). With uric acid
oxalate, xanthine or metric) crystals along the calyceal
walls, both kidneys, seen obstructed at present. No
enlarge lymph nodes seen. With enlarge prostate
gland, approximately 34.57 grams +.
 X – Ray Report
( Chest X-ray)
11/21/09
• Impression: Left pleurodiaphragmatic
adherences. Arteriosclerosis of the thoracic
aorta

E.C.G.
11/19/09
Impression: Sinus rhythm w/ nonspecific ST-T
wave changes.
ANATOMY &
PHYSIOLOGY
Blood
- consists of cells and cell fragments
suspended in an intercellular matrix and
about 5 liters in the adult human and
accounts for 8 percent of the body weight

- formed in bone marrow, the soft

spongy center of the bones.
 - The activities of the blood may be
categorized as

1. Transportation

2. Regulation

3. Protection.
TRANSPORT FUNCTIONS

 carrying oxygen and nutrients to the cells.

 transporting carbon dioxide and

nitrogenous wastes from the tissues to the
lungs and kidneys.

 Carrying hormones from the endocrine

glands to the target tissues.
REGULATION FUNCTIONS

 Helping regulate body temperature

 Playing a significant role in fluid and

electrolyte balance

 Functioning in pH regulation
PROTECTIVE FUNCTIONS

 Preventing fluid loss

 Helping (phagocytic white-blood cells)

to protect the body against
microorganisms

 Protecting (antibodies in the plasma)

protect against disease
Compositions of
Blood
Plasma

- The watery fluid portion of

blood (90 percent water) in which
the corpuscular elements are
suspended
• It transports nutrients as well as
wastes throughout the body. Various
compounds, including proteins,
electrolytes, carbohydrates,
minerals, and fats, are dissolved in it.
Formed Elements

1. erythrocytes (red blood cells)

2. leukocytes (white blood cells)

3. thrombocytes (platelets)
Erythrocytes (red blood cells)

- tiny biconcave disks, thin in the middle

and thicker around the periphery

FUNCTION:

- transport oxygen and, to a lesser

extent,carbon dioxide.
Leukocytes (white blood cells)

- are phagocytic, others produce

antibodies, some secrete histamine and,
heparin, and others neutralize histamine

FUNCTION:

- provide a defense against organisms

that cause disease and either promote or
inhibit inflammatory responses.
TWO MAIN GROUPS OF LEUKOCYTES

1.Granulocytes
- Cells that develop granules in cytoplasm
- (Neutrophils, Eosinophils, and Basophils)

2. Agranulocytes
- those that do not have granules
- (Monocytes and Lymphocytes )
GRANULOCYTES
Eosinophils
- help counteract the effects of histamine.

Basophils (Mast Cells)

- secrete histamine and heparin and have
blue granules.

Neutrophils
- the most numerous leukocytes, are
phagocytic and have light-colored granules
AGRANULOCYTE
S
MONOCYTES

1. replenish resident macrophages under

normal state

2. in response to inflammation signals,

monocytes can move quickly (approx. 8-12
hours) to sites of infection in the tissues and
divide/differentiate into macrophages and
dendritic cells to elicit an immune response.
Lymphocytes
- plays an important role in
immune processes

- Some attack bacteria directly;

others produce antibodies
Thrombocytes (platelets)

- are small fragments of very large cells

called megakaryocytes

- clumps together to form platelet

plugs that close breaks and tears in blodd
vessels.

- initiate formation of blood clots

BONE MARROW

- is the spongy tissue where blood cell

development takes place

- activates at birth but by the time a

person reaches young adulthood, the bones of
the hands, feet, arms, and legs no longer have
functioning marrow.
 HEMATOPOISES
The production of formed elements, or
blood cells

occurs primarily in the liver and spleen,

but some cells develop in the thymus,
lymph nodes, and red bone marrow.
PATHOPHYSIOLOG
Y
RISK FACTORS: PRECIPITATING
FACTORS:
> Genetic
Factors >Chemical
> Age exposure
> Gender
 THE

MEDICAL

MANAGEMENT
DOCTOR’S

ORDERS
 November 19, 2009
• Omeprazole (omepron) 20mg 1 tab once a day after
breakfast
Decreases acid in the G.I.T. by inhibiting proton pump
• BP, TPR every shift
Provide a baseline data for care.
Complete Blood Count
R. Determines hematologic status of the patient
• secure 3 units pack red blood cells with patient’s blood
type screened crossmatched as stand by.
Used to increase RBC count
• activity: bed rest
• Oxygen as needed
Necessary for promotion of normal O2 levels
11:20 AM
• please transfuse 3 units pack red blood cells
4Hours interval properly screened & crossmatched
use pts. Bloodtype. Blood type transfuse once
available
Used to increase RBC count
3:30 PM
• please secure consent for bone marrow biopsy
Consent is essential for any treatment; routine
procedures are covered by a consent signed at
admission
• to schedule for Hema-Onco unit
tomorrow morning , once with consent.
Determines malignancy of involved
blood cells
• Ultrasound -whole abdomen tomorrow.

Used to look at lymph nodes near the

surface of the body or to look for
enlarged organs inside your abdomen.
 November 21, 2009
9:15 AM
• to include reticulum staining with bone marrow specimen.
Determines increasing lymphocytes and decreasing other
blood components
• Secure and transfuse 4 units pack red blood cells
Used to increase RBC count
• Complete Blood Count post Blood Transfusion
Determines hematologic status of the patient
9:45 AM
• for chest X-ray
To check lung status since patient complained shortness
of breath.
 NOVEMBER 22, 2010
Complete Blood Count on morning noted with 6
Hours post Blood transfusion
Determines hematologic status of the patient

November 23, 2009

• paracetamol (Tylenol) 650 m ER tab give 1 tab by
by mouth Round The Clock for 8 doses every 6
Hours
Produces analgesia by inhibiting prostaglandins.
Also relieves fever by central action in the
hypothalamus
• Folic acid (5mg cap) Give 1 cap by mouth after
breakfast once daily
Stimulates normal RBC production

• Epoetin beta (10, 000 iu PFS) Give 10,000 units

subcutaneous before discharge.

Enhances RBC production by stimulating

mitotic activity of erythroid progenitor cells and
early precursor cells.
 January 19, 2010
3:00 PM
• PNSS 500cc @ 100 cc/hr.
Maintains fluid balance
• For Blood Transfusion 3 units pack red blood cells properly
screened & crossmatched
Used to increase RBC count
3:50 PM
• Pls. retrieve old charts
Provide a baseline data for care.
• Transfuse 3 units pack red blood cells once available, 4Hours apart
Used to increase RBC count
• Complete Blood Count 6 Hours apart post blood
transfusion

January 20, 2010

• Pls. attach official bone marrow studies & biopsy
results to chart.

The results of these tests serve as a baseline

that is used later on to assess the effects of
treatment.
 January 21, 2010
5:00 AM
Pls. secure another 2 units pack red blood cells of

patient’s blood type, properly screened & crossmatched.

Used to increase RBC count
7:00 AM
Start Prednisone 30 mg. 2 tab. Once Daily after
breakfast.
Suppresses immune response and stimulates bone
marrow.
Omeprazole 20 mg. 1 tab. Once Daily before breakfast

Decreases acid in the G.I.T. by inhibiting proton pump

 January 22, 2010

• please transfer available 2 units pack red blood

cells
Used to increase RBC count
• Complete Blood Count 6 Hours apart post
Blood Transfusion
 January 23, 2010
12:00 AM
 Captopril 25 mg.
Lowers BP by inhibiting ACE thus decreasing aldosterone
secretion which reduces Na and H2o retention.
10:00 AM
 May Go Home please relay Complete Blood Count results
@ discharge
 prednisone & omeprazole as take home meds
Suppresses immune response and stimulates bone
marrow.Decreases acid in the G.I.T. by inhibiting proton
pump
 clinic ff. with CBC on Feb. 2,2010
 THE

NURSING

MANAGEMENT
 ACTUAL CARE GIVEN
• The student nurse assigned took the vital signs of my
patient and plotted it in the chart. Intake and Output
was also measured and recorded. Patient was asked
some questions for our additional data and listened to
his stories and needs and did assessment. Student nurse
stayed for a while in the patient’s room to attend his
needs and check on his condition. Staff nurse gave
patients due medications and student nurse gave health
teachings about how to deal with cancer condition, as
well as with patients family.
 THE
NURSING
CARE
PLAN
DIAGNOSIS:

• Ineffective breathing pattern

r/t compression of diaphragm
secondary to splenomegaly.
CUES:
No Subjective cues
 
Objective cues:
 
- difficulty in breathing noted
-pallor noted
-Respiratory rate of 30 cycles per
minute
-use of accessory muscles noted
 SCIENTIFIC BASIS
• The uncontrolled growth of b lymphocytes causes
overcrowding of the bone marrow that initiates circulation
of bone marrow in the blood causing increase levels of WBC. as
the blood passes through the spleen. Having the essential
role of filtering waste and foreign substances and
recognize it as abnormal mature lymphocytes as foreign
materials then triggers the spleen’s filtering mechanism
leading to accumulation of WBC resulting to enlarge
spleen. Oversize spleen compresses diaphragm thus
causing ineffective breathing pattern.
DIAGNOSIS:

• Ineffective tissue perfusion

related to decreased RBC
levels in the blood secondary
CLL.
Subjectives Cues

No Subjective Cues

Objective Cues:
-Weakness noted
- Paleness of the skin noted
-Decreased levels of RBCs
Laboratory findings: 4.0
with a hemoglobin level of 10 M/µL
 SCIENTIFIC BASIS

In Chronic Lymphocytic Leukemia there is

abnormally high levels of mature b-lymphocytes
because of the prolifeative process of
synthesizing lymphocytes in the bone marrow,
this overcrowds the blood with with b-
lymphocytes resulting in the reduced amount of
RBCs circulating in the system in which RBCs has
the capability of carrying oxygen for tissue
perfusion.this leads to inefffective tissue
perfusion
 NURSING DIAGNOSIS

Fatigue related to low

hemoglobin levels
secondary to Chronic
Lymphocytic Leukemia
Subjective Cues:

“Kapoy ayu ako lawas dai”, as verbalized by the

patient

Objective Cues:
>limited movements noted 
>Lethargy and listless noted
>hemoglobin of 10 g/dL
>decreased performance
>report of weakness
 SCIENTIFIC BASIS
 In CLL there is pancytopenia , the over- crowded
bone marrow, filled with abnormal B lymphocyte.
After the normal synthesis of immature RBC’s in the
bone marrow. The decreased and suppressed levels
of erythrocytes circulating in the system, RBC’s
contain the constituting heme in which oxygen
attached. By the decreased of RBC level in the blood
oxygen transport is decreased, making the cells
poorly perfused. This causes poor cerebral tissue
perfusion , resulting in muscle weakness, lethargy
and fatigue . (Black & Hawks, 2008: pg. 2123)
 GOALS AND OUTCOME
CRITERIA
• After 8 hours of rendering nursing
interventions, the patient will report less
fatigue and report an improved sense of
energy as evidenced by increased level of
interest in daily routines, wakefulness
with a better activity performance.
Outcome Criteria:

1. The patient will verbalize ways of achieving

optimal performance from the desired set of
medical and nursing activities.
NURSING ACTIONS & RATIONALE OF NURSING
NURSING ORDERS ORDERS
Independent:
1. Assess specific cause of •Fatigue is a characteristic
fatigue side effect of leukemia
treatment or reduces
oxygen-capacity of blood.
However, patients may
exhibit lack of interest in
performing activities.
(Gulanick & Myers, 2007:
pg. 866)
2. Have client rate fatigue •Helps in developing a plan for
using a numeric scale, if managing fatigue. (Doenges
possible, and the time of et al., 2006: pg. 870)
day when it is most severe.

3. Instruct patient not to •In order to avoid injury. (Black

perform exercises who just & Hawks, 2008: pg. 2123)
received chemotherapy
(past 24 hours).
Collaborative:
1. Refer to •Programmed daily exercises &
physical/occupational activities help client
therapy. maintain/increase strength &
muscle tone. Use of adaptive
devices may help conserve
energy. (Doenges et al., 2006:
pg. 870
To assist with bed &
strengthening exercises. (Black
& Hawks, 2008: pg. 2123)
Outcome Criteria:

2. The patient will perform &

participate in desired activities at level
of ability.
NURSING ACTIONS & RATIONALE OF NURSING
NURSING ORDERS ORDER
Independent:
1. Stress importance of •Energy reserves may be
frequent rest periods depleted unless the patient
respects the body’s need for
increased rest. (Gulanick &
Myers, 2007: pg. 867)

2. Advice patient or S.O.s

2. To have adequate rest and
to reduce visitors.
minimize interruptions. (Black
& Hawks, 2008: pg. 2123)
Dependent:

1. Anticipate need for •These increase oxygen-

transfusion of packed carrying capacity of the
red cells. blood. (Gulanick & Myers,
2007: pg. 867)
Outcome Criteria:

3. The patient will develop positive

attitude in performing ways of
reducing fatigue and desired
activities.
NURSING ACTIONS & RATIONALE OF NURSING
NURSING ORDERS ORDER
Independent:
1. Assess current and •These provide basis for
desired activity level. development of treatment
plan. (Gulanick & Myers,
2007: pg. 867)

•Patients and caregivers may

2. Teach energy-
need to learn skills for
conservation principles.
delegation of tasks to others,
setting priorities and
clustering care to use
available energy to completer
desired activities. (Gulanick &
Myers, 2007: pg. 867)
3. Assist patient in planning •Not all self-care activities
ADLs need to be completed in the
morning. Likewise, not all
housework needs to be
completed in one day.
(Gulanick & Myer, 2007:
867)
Dependent:

1. Instruct pt. to have a •Supplies proteins & vitamins

balanced diet & vitamin & necessary to build or
mineral supplementation. maintain body tissues.
(Kozier et. al, 2007; pg. 683)
 EVALUATION
Goal met, patient was able report
less fatigue and do an increasing
amount of ADL.
DISCHARG
E PLAN
 PATIENTS OUTCOME NURSING ORDERS
CRITERIA
As soon as the patient will
be discharged, the patient
and his family will be able
to perform the following:
 
ASSESSMENT
Teach the SO do vital signs
Patient/Significant Others taking.
will be able to assess his/ Instruct the patient SO to
observe signs of infection;
the patient’s condition fever, chills, swelling of lymph
regularly. nodes. If signs do appear Visit
Patient/Significant Others Note lifestyle changes,
will be able to identify basis expanded responsibilities/
of fatigue and individual job related conflicts
areas of control

Encourage patient or SO to
make a schedule and note
down the time to take each
drug and diligently take the
prescribed medication.

Encourage patient/SO to take

the drugs at the right time
PLANNING Encourage the patient
Plan for follow-up/ to have a regular visit
check up in the in the nearby hospital
hospital or in the near or clinic
clinic.
 
IMPLEMENTATION
M – Patient will be able
to comply with the
medication prescribed
by the physician.
Prednisone  
Document the medicaton
given.

Observe for any unsualities

such as severe confusion it
might indicate adverse reaction

Evaluate the effectiveness of

the drug given.

Omeprazole Document the medication given.

Note for decrease urine output

Evaluate effectiveness of drug

given as evidence by pain in the
Captopril Document the medication given

Note for decreased BP below

60 it cause hypotension.

Evaluate the effectiveness of

the drug given as evidenced by
BP is within normal range
120/80.
Folic Acid Take only as directed. Avoid
alcohol
Dietary sources of folic acid
include dark green leafy
vegetables, beans, fortified
breads, and cereals.
Drug may discolor urine a deep
Epoetin Beta Do not shake vial; this
inactivates drug. Keep drug
refrigerated

Supplemental iron and

vitamins are administered to
enhance drug effects; take as
directed.

Review list of drug side

effects; report
persistent/bothersome ones.

Practice contraception during

therapy
E – Patient/SO will provide
clean environment which is
free from infectious agents
and to allow patient to rest
with a clean surrounding.
Have the company of
Support systems (e.g. Family,
friends, church/ religion)
Encourage patient to have a
well ventilated environment
Encourage the SO and the
patient to clean environment
specially their own backyard
or place to allow good rest
and stress free surroundings
for the patient to regain
strength and comfort.
T – The patient will be Instruct the patient to
able to comply with the follow the doctor’s order
treatment needed. for his treatment.

H – Patient/SO will be Discuss health teachings

able to absorb the health to the patient and SO and
teachings of the allow them to ask
healthcare provider questions for further
information..
O – Patient will be able to plan Encourage frequent resting
for a visit in a clinic or hospital periods
for a check-up.

D – Patient/SO will be able to Instruct the patient to follow

identify and comply with the the diet ordered by the
appropriate diet. physician to avoid any
alterations.

Intake of iron supplements as

prescribed, and fat-soluble
vitamins A,D,E,K

Diet that includes rich in vitamin

C , plant sources that are rich in
protein (e.g peanuts, legumes
and beans), carbohydrates.
 S – patient will be able to Teach patient to ask
strengthen his faith and guidance from God
will be able to cope on his
condition

EVALUATION
Patient/SO will be able to Teach the patient and the
evaluate his/clients SO how to appreciate the
condition if client improvement of his/ the
responded positively to patient’s health status
the regimens rendered.
 EVALUATION OF CARE
• Interventions were done for the patient to get well and feel
that he is well taken care of during his stay. The student was
able to help him not only physically but psychologically as
well. Patient constantly asks questions with regards to
student nurse’s health teachings and trusted the student
nurse not only with the nurse’s care but also details about
her life. We were optimistic that he will be able to perform
the health teachings by the time he gets home. We were
very glad when he thanked us of the time we spent with
him and that the student nurse was very understanding and
patient with him. We visited the patient in his residence last
January 31, 2010 and found out that he was healthy and
was never admitted again. It truly showed that the
interventions we gave him had a positive effect on him.