leukemia - Nursing Case Study

Pathophysiology

• Primary mechanism: Leukemia is primarily characterized by the overproduction of abnormal white blood cells, originating from a single cell that has undergone genetic mutation. These leukemic cells cannot perform their normal function of fighting off infections and they continue to grow and divide, crowding out normal cells in the bone marrow.

• Secondary mechanism: As leukemia progresses, the abnormal cells spill into the bloodstream, spreading to other parts of the body. This can lead to various complications such as anemia (due to lack of red blood cells), infections (due to dysfunctional white blood cells), and excessive bleeding (due to insufficient platelets).

• Key complication: Leukemic cell infiltration into organs like the spleen, liver, and central nervous system can cause organ dysfunction. For instance, infiltration into the central nervous system may lead to neurological symptoms such as headaches, seizures, and loss of muscle control.

Patient Profile

Demographics:

52-year-old female, high school teacher

History:

• Key past medical history: Diagnosed with Acute Lymphoblastic Leukemia (ALL) 2 years ago, Hypertension

• Current medications: Vincristine, Prednisone, Methotrexate, Lisinopril for hypertension

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent fatigue, unexplained weight loss, and frequent infections

• Key symptoms: Noticeable weakness, shortness of breath, swollen lymph nodes, easy bruising, night sweats, bone pain

• Vital signs: Blood Pressure - 145/90 mmHg, Pulse - 110 bpm, Temperature - 99.1°F, Respiratory rate - 22 breaths per minute, Oxygen saturation - 94% on room air

Section 1

New Diagnostic Results:

The patient's lab results have returned with several notable findings. Her complete blood count (CBC) showed a significant decrease in red blood cells, indicating anemia, with a hemoglobin level of 8 g/dL (normal range: 12-16 g/dL). The white blood cell count was elevated at 45,000 cells/mcL (normal range: 4,500-11,000 cells/mcL), with the majority being immature lymphocytes, and the platelet count was low at 50,000/mcL (normal range: 150,000-450,000/mcL).

Her peripheral blood smear showed a high number of lymphoblasts, suggesting a relapse of her ALL. Lactate dehydrogenase (LDH), a potential marker for cell damage and rapid cell turnover, was also markedly elevated at 900 U/L (normal range: 140-280 U/L). These results indicate an aggressive proliferation of leukemic cells, which is causing a decline in her overall cell counts and organ function. This is consistent with her symptoms of fatigue, weakness, shortness of breath, and easy bruising.

The clinical team will need to evaluate these findings and consider treatment adjustments. They should also consider further diagnostic testing, such as a bone marrow biopsy, to confirm the diagnosis and assess the extent of the disease. The patient's history of hypertension and ongoing symptoms should also be factored into the clinical decision-making process.

Section 2

Change in Patient Status:

Over the following days, the patient's condition became increasingly unstable. She developed a fever of 101.6°F, her pulse rate increased to 110 beats per minute, and she exhibited signs of pallor and increased fatigue. She also complained of a new onset of bone pain, primarily in her lower back and sternum, which further suggested progression of the leukemia.

In addition, she developed petechiae and ecchymosis on her extremities, signs of a decreased platelet count and impaired clotting. Her latest lab results showed a further decline in platelet count to 30,000/mcL and hemoglobin to 6.5 g/dL. White blood cell count had also increased to 55,000 cells/mcL, with predominantly immature lymphocytes. This clinical picture indicates a rapid proliferation of leukemic cells and worsening of her overall condition.

The clinical team will have to reassess the patient's treatment plan, factoring in her worsening symptoms, elevated temperature, and the rapid decline in her lab values. Aggressive intervention may be required to mitigate the symptoms and control the rapid progression of the disease. Further diagnostic testing may also provide more information on the extent of the disease and guide the clinical decision-making process.

Section 3

New Diagnostic Results:

In response to her worsening condition, the patient was sent for a bone marrow biopsy to determine the extent of leukemic infiltration. The results indicated a high percentage of blast cells in the marrow, confirming an aggressive progression of her leukemia. Imaging studies, including a full body PET scan, was also performed. The scan revealed multiple areas of increased metabolic activity, suggesting the presence of leukemic cells in her bones, particularly her sternum and spine, which correlated with her reported sites of pain.

Further laboratory testing showed an increase in her lactate dehydrogenase (LDH) levels to 900 U/L, indicative of increased cell turnover or cell destruction. Her blood culture results came back positive for Staphylococcus aureus, likely explaining her persistent fever and suggesting a bloodstream infection. The combination of her declining health, positive blood culture, and increasing leukemic cell population necessitates a reevaluation of her treatment plan. The clinical team must now consider a more aggressive approach, perhaps including a combination of antibiotics, chemotherapy, radiation therapy, and potential bone marrow transplant. The team's decisions must take into account her overall health, the aggressiveness of the leukemia, and the potential risks and benefits of each treatment option.

Section 4

Change in Patient Status:

Over the next few days, the patient's condition continued to decline. She became increasingly fatigued and complained of severe bone pain, particularly in the areas identified in the PET scan. She also developed a persistent cough and began to experience difficulty breathing. Her oxygen saturation levels dropped to 90% on room air, her heart rate increased to 120 beats per minute, and her respiratory rate increased to 24 breaths per minute. On physical examination, she appeared pale and her skin was cool and clammy. Her lungs were clear to auscultation, but her breath sounds were shallow and rapid.

These new developments suggest that the leukemia may be affecting her lung function - a complication known as leukemic infiltration of the lungs. This could explain her cough and difficulty breathing, as well as her increased heart rate as her body tries to compensate for the reduced oxygenation. It also raises the concern of potential septicemia due to the positive blood culture for Staphylococcus aureus, which would further compromise her already weakened immune system. The clinical team must now consider additional interventions, such as supplemental oxygen, and possibly a bronchoscopy to further assess her lung status. The team must also reassess her antibiotic regimen to ensure it is effectively treating the Staphylococcus aureus infection. This situation calls for clinical reasoning to balance the need for aggressive treatment of her leukemia with the need to manage her emerging complications and declining respiratory status.

Section 5

Change in Patient Status:

The patient's condition further deteriorated over the following hours. The supplemental oxygen provided only slight relief and her oxygen saturation levels remained low, fluctuating between 88-91%. Her respiratory rate increased to 28 breaths per minute, her heart rate remained at 120 beats per minute, and she developed low-grade fever of 100.4°F. The patient also reported increased bone pain and persistent fatigue. Her blood pressure dropped slightly to 100/60 mmHg, indicating possible onset of septicemia.

New Diagnostic Results:

A repeat blood culture confirmed the presence of Staphylococcus aureus in the patient's bloodstream, indicating a systemic infection. Her white blood cell count had spiked to 45,000 cells/mcL, well above the normal range of 4,500-11,000 cells/mcL, suggesting that the leukemia was progressing. Her hemoglobin levels also dropped to 8g/dL from the earlier 10g/dL, indicating worsening anemia. The bronchoscopy showed scattered areas of inflammation and consolidation, confirming the suspicion of leukemic infiltration in the lungs.

The clinical team now faces the challenge of managing the patient's worsening septicemia while also addressing her declining respiratory status and progressing leukemia. The current antibiotic regimen appears to be ineffective, and a change in medication, possibly to a broader spectrum antibiotic, may be warranted. Additionally, the team may need to consider more aggressive interventions, such as chemotherapy or a bone marrow transplant, for the leukemia.