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    Leukemia Case Study

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    Leukemia Case Study

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    Leukemia Case Study

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    dsaitta108
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    Leukemia Case Study

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    Leukemia Case Study

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    1K views32 pages

    Leukemia Case Study

    Uploaded by

    dsaitta108
    Leukemia Case Study

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
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    The document discusses different types of leukemia and acute lymphoblastic leukemia (ALL) as well as hematopoietic stem cell transplantation as a treatment for ALL.

    The common types of leukemia mentioned are acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), chronic myeloid leukemia (CML), and chronic lymphocytic leukemia.

    ALL is a type of cancer that affects the lymphoid stem cells. It starts from immature white blood cells called lymphoblasts in the bone marrow.

    CASE STUDY #32

    ACUTE LYMPHOBLASTIC
    LEUKEMIA TREATED WITH
    HEMATOPOIETIC STEM CELL
    TRANSPLANTATION

    Ka r l y C h il d re s s
    Denielle Saitta
    M o ll y C h a ffi n
    C l a i re H o ll a d a y
    L a u re n M i t c h e l l

    ACUTE LYMPHOBLASTIC LEUKEMIA


    Leukemia is a type of cancer that aff ects the blood
    and bone marrow
    Common Types of Leukemia:

    Acute Myeloid Leukemia (AML)


    Acute Lymphoblastic Leukemia (ALL)
    Chronic Myeloid Leukemia (CML)
    Chronic Lymphocytic Leukemia

    Patients with acute leukemia have a more aggressive


    disease than those with chronic leukemia

    ALL, CONT.
    Bone marrow makes bloo d
    st em cells t hat b ecom e
    mat ure bloo d cells over t im e
    A bloo d st em cell may
    become a m yelo id stem c ell
    or a lympho id stem cell
    Myelo id st em cell bec om es
    one of t hree t ypes of m a ture
    blo od cells
    Red blood cells
    Platelets
    White blood cells

    Lymphoid stem cell beco m es


    a lympho blas t cell and t hen
    one of t hree t ypes of
    lymphocyt es
    B lymphocytes
    T lymphocytes
    Natural killer cells

    SIGNS AND SYMPTOMS OF ALL

    HEMATOPOIETIC STEM CELL


    TRANSPLANTATION
    Hematopoietic stem cell transplant is a procedure
    that restores stem cells that have been destroyed by
    high doses of chemotherapy and/or radiation therapy
    Three types of transplants:
    Autologous transplant
    Allogeneic transplant
    Syngeneic transplant

    MEET SCOTT BEAR

    CLIENT HISTORY (CH)


    Personal History

    28 year old, white male


    Marital Status: Married with three children
    Tobacco use: pack daily, states he quit this morning
    Alcohol use: 1 drink daily, beer or alcohol
    Mobility: Ambulatory

    Hematology/Oncology History
    Chief Complaint: Im here to get some new cells.
    Diagnosed with ALL in 2008
    He was doing well until Spring 2012
    Admitted with fever, fatigue, dyspnea, and red spots on his skin
    Diagnosis: Relapse of Pre-B cell ALL and started on HyperCVAD (5
    cycles prior to admission)

    CLIENT HISTORY (CH)


    Musculoskeletal History
    osteomyelitis, back pain
    Psychological History
    anxiety, depression

    Family History
    Mother: Diabetes
    Father: Hypertension

    Other History
    Obesity
    Treatments/Therapy
    Surgical treatment
    ALL admitted to the transplant unit for a 10/10 HLA matched
    unrelated donor transplant with myeloablative
    cyclophosphamide and total body irradiation

    CLIENT HISTORY (CH)


    Admission Orders (11/7)
    ALT/AST, Bilirubin: total and direct
    CMV, PT, IRN, PTT: on admit and every Monday/Thursday
    Calcium/Phosphate: on admit and every Monday/Thursday
    CVC, Edit, Platelet: on admit and every two days
    Chem 7, Magnesium: on admit and daily
    Prealbumin: on admit
    Vital Signs
    Every 4 hours
    Diet: Regular/Low bacterial

    ANTHROPOMETRIC MEASUREMENTS
    (AD)
    Height: 59
    Weight: 198 lbs
    BMI: 29.4 kg/m 2
    Overweight

    50lb unplanned weight loss during fi rst round of


    chemotherapy (2008)
    22% unplanned weight loss
    Regained 20 lbs to current 198lb

    NUTRITION-FOCUSED PHYSICAL
    FINDINGS (PD)
    Upon Admission (11/7)
    Overall Appearance
    Comfortable, not in acute distress, well-nourished
    Skin warm and dry, not perspiring

    Chest/Abdomen
    Clear to auscultation
    Abdomen: soft, nontender, nondistended

    Vital Signs

    Temp: 98.2
    Pulse: 80
    Resp rate: 16
    BP: 126/78

    NUTRITION-FOCUSED PHYSICAL
    FINDINGS (PD)
    16 days post-op
    Overall Appearance
    Macropapular rash on palms and trunk
    Grade 2 mucositis in mouth

    Chest/Abdomen
    Clear to auscultation
    Firm, tense hyperactive BSx4

    Vital Signs (16 days post-op)

    Temp: 98.4
    Pulse: 83
    Resp rate: 20
    BP: 130/82

    BIOCHEMICAL DATA, MEDICAL


    TESTS AND PROCEDURES (BD)
    Lab

    Reference
    Range

    Admission

    Post-op day 16

    BUN (mg/dL)

    8-18

    13

    23 H

    BUN/Crea ratio

    10.0-20.0

    13

    23 H

    Albumin (g/dL)

    3.5-5

    3.5

    2L

    Prealbumin
    (mg/dL)

    16-35

    24

    <1 L

    BIOCHEMICAL DATA, MEDICAL


    TESTS AND PROCEDURES (BD)
    Hematology
    Lab

    Reference
    Range

    Admission

    Post-op day 16

    WBC count
    (x103/mm3)

    4.8-11.8

    4.5 L

    2.9 L

    RBC count
    (x106/mm3)

    4.5-6.2 (M)

    2.82 L

    2.33 L

    Hemoglobin
    (Hgb, g/dL)

    14-17 (M)

    9.8 L

    7.9 L

    Hematrocrit (Hct, 40-54 (m)


    %)

    29.1 L

    23.7 L

    Mean Cell Hgb


    (pg)

    26-32

    20.4 L

    16.5 L

    RBC distribution
    (%)

    11.6-16.5

    7.6 L

    8.9 L

    FOOD AND NUTRITION-RELATED


    HISTORY (FH): FOOD AND
    NUTRIENT INTAKE
    48-hour food recall shows regular and suffi cient food
    intake
    Likely meeting >100% of calorie and protein needs

    FOOD AND NUTRITION-RELATED


    HISTORY (FH): FOOD AND
    NUTRIENT INTAKE
    Current Medications upon admission (11/7)

    FOOD AND NUTRITION-RELATED


    HISTORY (FH): FOOD AND
    NUTRIENT INTAKE
    Medication Plan as of 11/30

    FOOD AND NUTRITION-RELATED


    HISTORY (FH): FOOD AND
    NUTRIENT INTAKE
    Medication Plan as of 11/30, cont

    FOOD AND NUTRITION-RELATED


    HISTORY (FH): FOOD AND
    NUTRIENT INTAKE
    Medication Plan as of 11/30, cont

    COMPARATIVE STANDARDS (CS)


    REE (using Miffl in St. Jeor equation):
    (10 x 90 kg) + (6.25 x 175cm) (5 x 28 y) + 5 = 1,858.75
    kcal/day

    TEE
    1.2 Activity Factor (hospitalized)= 2,230 kcal
    1.0-1.3 injury factor due to surgery
    2,230-2,900 kcal/day

    COMPARATIVE STANDARDS (CS)


    Macronutrient needs
    Normal protein requirements (0.8-1.0 g/kg body weight)
    = 72-90 g/day

    Post-operative needs (1.0-1.5g/kg body weight)


    = 90-135 g/day

    Fluid needs: 1mL/kcal consumed


    2.2-2.9 L/day = 9 (8 oz.) glasses per day

    Fiber needs = 31 g/day

    COMPARATIVE STANDARDS (CS)


    Micronutrient Needs

    Calcium: 1,000 mg/day


    Vitamin D: 15 mcg/day
    Potassium: 4,700 mg/day
    Selenium: 55 mcg/day
    Vitamin B6: 1.3 mg/day

    NUTRITION DIAGNOSES
    PES #1:
    Altered GI function (NC-1.4) related to chemotherapy and
    total body irradiation as evidenced by 3.5 L liquid stool past
    24 hours.

    PES #2:
    Altered nutrition related lab values (WBC, NC-2.2) related to
    cancer treatment as evidenced by 2.9 White blood cell
    count.

    NUTRITION INTERVENTION
    PES #1: Altered GI function (NC-1.4) related to
    chemotherapy and total body irradiation as evidenced
    by 3.5 L liquid stool past 24 hours.
    Nutrition Rx: Meeting nutritional needs through
    bypassing the GI tract..
    Nutrition Intervention: Initiate Parenteral Nutrition (2.2)
    Dextrose: 571 mL ; D70 ; 400g 1360 Kcals
    A A:
    900 mL ; 15% A A; 135g 540Kkcals
    IVFE:
    200 mL ; 20% IVFE ; 40g 400 Kcals
    Total: 2,300 Kcals

    NUTRITION INTERVENTION
    PES #2: Altered nutrition related lab values (WBC, NC2.2) related to cancer treatment as evidenced by 2.9
    White blood cell count.
    Nutrition Rx: Modify diet to a low microbial diet with high
    protein, adequate energy.
    Nutrition Intervention: A low microbial diet includes
    avoiding raw/undercooked foods such as seafood, eggs,
    vegetables, undercooked meats, unpeeled fruits, or
    unpasteurized dairy products. This diet will reduce the
    chance of Mr. Bear becoming ill while his immune system
    is weak. Educate the patient on the importance of food
    safety and how this contributes to the low microbial diet.

    MONITORING AND EVALUATION


    Monitor anthropometrics by checking weight, BMI, and waist
    circumference to prevent weight loss
    Evaluate the patients knowledge of the microbial diet and
    what he should and should not eat when his immune system
    is suppressed
    Evaluate the patients re cell blood counts in order to reduce
    chance of infection
    Increase the patients fi ber and water intake to reduce the
    chance of diarrhea
    Monitor the patients protein levels in order to keep blood
    counts high and stable
    Monitor patient for symptoms of GVHD ( Graft-versus-host
    disease) such as jaundice, abdominal pain, dry or irritated
    eyes, fatigue, muscle weakness, weight loss, etc
    Monitor White Blood cells Counts
    Monitor patients energy intake as well as macronutrients
    intake

    ADIME NOTES
    Client History
    28 y/o white male, married with 3 children
    Acute lymphoblastic leukemia (ALL)
    Admitted to transplant unit for a 10/10 HLA MUD with
    myeloablative cyclophosphamide and total body irradiation
    1 alcoholic drink daily and smokes pack daily

    Anthropometric Data
    Height: 59 Weight: 198 lbs BMI: 29.4

    Physical Findings
    Macropapular rash on palms and trunk
    Grade 2 mucositis in mouth
    Patient reports feeing fatigued, complains of mouth
    pain/discomfort from rash
    Diarrhea continues with occasional nausea

    Vital Signs
    Temperature: 98.4 Pulse: 83 Blood Pressure: 130/82

    ADIME NOTES
    Biochemical Data

    ADIME NOTES
    Food and Nutrition Related History
    Patient states that usual body weight was 230 lbs
    Prior to diagnosis and with initial chemo treatment in
    2008, patient lost 50 lbs. The next year, patient
    gained 20 lbs
    48-hour recall shows intake prior to admission good
    and likely meeting >100% of calorie and proteins
    needs

    Comparative Standards
    Kcal: 1,858.75 kcal/day
    Protein: Post-op 90-135 g/day
    Fluid: 2.2-2.9 L/day = 9 (8 oz.) glasses per day

    ADIME NOTES
    Dia gnosis & In t er v en ti on
    PE S #1 :Al te red GI fu n ct ion (NC- 1 .4 ) rel a t ed t o c hem ot h er a py a n d to ta l
    body irr a dia ti on a s ev i de nce d by 3 .5 L li qui d st ool pa st 2 4 h ou r s.
    Nut r it ion R x : M e et in g n utr i tio na l ne eds t hrough by pa ssin g t h e G I t r a c t.
    Nut r it ion In t er v en ti on : Ini tia te Pa rent er a l Nutr i ti on ( 2 .2 )
    Dex t rose: 5 7 1 m L ; D7 0 ; 4 0 0g
    1 3 6 0 K c a ls
    A A:
    9 0 0 m L ; 1 5 % A A; 1 3 5 g 5 4 0 Kk c a ls
    IV F E :
    2 0 0 m L ; 2 0 % IVF E ; 4 0 g 4 0 0 K ca ls
    Total: 2,300 Kcals
    PE S #2 : Alt ere d n u tr i tio n rela te d la b v a lue s (W BC, NC- 2 .2 ) rel a te d t o
    ca nce r t rea tm e nt a s ev i de nce d by 2 .9 W hi te blo od c ell c ou n t
    Nut r it ion R x : M odi fy di et t o a lo w m i crobia l di et w it h h igh prot ei n ,
    a dequa t e en ergy.
    Nut r it ion In t er v en ti on : This c a n be done t hrough a v oi din g
    r a w /underc ooked f oods ( sea foo d, e ggs, v eget a bl es, un derc ooke d
    m ea ts, unpee le d f ru i ts or unpa ste ur iz ed da ir y produ ct s. Thi s die t w i ll
    re duc e the ch a nc e of th e pa tie nt be co m i ng il l w hi le h is im m u n e
    sy st em i s w ea k. E du ca te the pa t ient o n the im por t a n c e o f f ood sa fe ty
    a nd how th is c on t r ibut e s to the lo w m ic ro bi a l die t.

    ADIME NOTES
    Monitor anthropometrics by checking weight, BMI, and
    waist circumference to prevent weight loss
    Evaluate the patients knowledge of the microbial diet and
    what he should and should not eat when his immune
    system is suppressed
    Evaluate the patients blood counts in order to reduce
    chance of infection through low blood counts
    Increase the patients fi ber and water intake to reduce the
    chance of diarrhea
    Monitor the patients protein levels in order to keep blood
    counts high and stable
    Monitor patient for symptoms of GVHD ( Graft-versus-host
    disease) such as jaundice, abdominal pain, dry or irritated
    eyes, fatigue, muscle weakness, weight loss, etc
    Monitor White Blood cells Counts
    Monitor patients energy intake as well as macronutrient
    intake

    REFERENCES
    Nahikian-Nelms, Marcia, and Sara Long. Roth. Medical
    Nutrition Therapy: A Case Study Approach . Belmont,
    CA: Wadsworth/Thomson Learning, 4 t h ed., copyright
    2014. Print.
    Internet Resources

    American Cancer Society: www.cancer.org


    National Cancer Institute: www.cancer.gov
    Nutrition Care Manual: www.nutritioncaremanual.org
    Dietary Guidelines for Americans 2010:
    www.dietaryguidelines.gov

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