Question

Leukemia and Bone Marrow Transplant Case Study Clinical

C.O. is a 43-year-old woman who noted a nonpruritic nodular rash on her neck and chest approximately 6 weeks ago. The rash became generalized, spreading to her head, abdomen, and arms and was accompanied by polyarticular joint pain and back pain. She experienced three episodes of epistaxis in 1 day about 2 weeks ago. Over the past week, her gums have become swollen and tender. Because of the progression of symptoms and increasing fatigue, she sought medical attention. Lab work was performed, and C.O. was directly admitted to the referred hematology/oncology unit of a teaching hospital under the care of a hematologist for diagnostic evaluation. Her chest x-ray (CXR) showed normal lung expansion, heart size normal, and no lymphadenopathy. Skin biopsy showed cutaneous leukemic infiltrates, and a bone marrow biopsy showed moderately hypercellular marrow and collections of monoblasts. Her lumbar puncture was free of blast cells. The final diagnosis was acute myeloblastic leukemia.

C.O. is to begin remission induction therapy with cytarabine (Ara-C) 100 mg/m 2  /day as continuous infusion for 7 days and idarubicin (Idamycin) 12 mg/m 2/day IV push for 3 days. She is scheduled in angiography for placement of a triple-lumen subclavian Hickman catheter before beginning her therapy.

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

Laboratory Test Results

CBC

WBC 39,000/mm 3

Monocytes 64%

Lymphocytes 15%

Neutrophils 4%

Blasts 17%

Hgb 10.4 g/dL

Hct 28.7%

Platelets 49,000/mm 3

2. What is the purpose of a bone marrow biopsy?

3. Considering all the admission data listed previously, what potential problem will the nurse be

alert for after the patient returns to the unit following insertion of the catheter?

4. What assessments are essential for the nurse to make regarding the central catheter

throughout the hospitalization?

5. What are the side effects of cytarabine (Ara-C) and idarubicin? Identify five nursing

interventions related to the side effects of each chemotherapeutic agent.

On the fifth day of continuous infusion of cytarabine (Ara-C), the NAP reports to you C.O.'s vital signs:

Vital Signs

Blood pressure 110/54 mm Hg

Heart rate 115 beats/min

Respiratory rate 26 breaths/min

Temperature 101.6° F (38.7° C)

6. What additional assessments should you make at this time?

CASE STUDY PROGRESS

You notify the intern on duty of your findings, who evaluates C.O. and writes the following orders:

Physician's Orders

Blood cultures now × 2 sites

Acetaminophen (Tylenol) suppository 650 mg q4-6 h prn

Primaxin (Imipenem) 500 mg IVPB q8h

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

7. Do these orders seem appropriate for this patient? Explain.

8. What will your next step be?

9. These are C.O.'s labs on the last day of the continuous chemotherapy. What does this count

indicate about her immune system?

10. Calculate C.O.'s absolute neutrophil count (ANC) and describe its significance.  To calculate an absolute neutrophil count (ANC), the formula is:  ANC = WBC × (% Neutrophils + % Bands)

11. Considering the previous data, what blood products will most likely be ordered for C.O.?

The patient will likely receive transfusions of red cells and platelets. These blood products will be

leukocyte reduced and irradiated. These processes will kill any donor WBCs that might engraft in the

patient marrow and cause a graft-versus-host disease, which would be fatal to the patient.

CASE STUDY PROGRESS

On day 14 after completion of her therapy, a bone marrow biopsy shows the patient is in complete remission. With continued blood product support and antibiotic coverage, her marrow recovers and she is discharged from the hospital. HLA (human lymphocyte antigen) typing has been performed on all siblings. Her oldest brother is a perfect HLA match and has agreed to donate bone marrow or stem cells. C.O. is to be readmitted to the bone marrow transplant unit within the next few weeks.

12. What does “complete remission” mean for C.O., and what impact did it have on the decision

to perform a bone marrow transplant?

Laboratory Test Values

WBC 1200/mm 3

Monocytes 25%

Lymphocytes 65%

Neutrophils 5%

Blasts 5%

Bands 0%

Hgb 6.8 g/dL

Hct 21.3%

Platelets 17,000/mm 3

13. What type of bone marrow transplant will she have? Briefly describe the transplant process.

14. On day 17 after the transplant, she develops severe nausea and vomiting in addition to

diarrhea of more than 1200 mL in 24 hours. Graft-versus-host disease of the gut is suspected.

Describe graft-versus-host disease.

15. Is there a potentially positive result of this complication? Explain your answer.

16. Identify four priority problems for a patient undergoing a bone marrow transplant, then develop interventions and expected outcomes for each problem

Answer 1

1. Presence of blasts shows increase n.o of immature precursor cells in bone marrow indicating signs of leukemia.

2. A bone marrow biopsy helps to evaluate the blood cells in cases of anemia, myelofibrosis, pancytopenia, aplastic anemia and other conditions which affect the red cell production.

3. The nurse should be alert to signs of hemothorax, nerve damage , hematoma, air embolism, arterial puncture, catheter misplacement etc.

4. Assessment includes perform hand hygiene, perform bed area safety check, perform head to toe assessment, inspect insertion site for any infection or redness, ensure the occlusive dressing is intact, ensure all i.vlines are securely connected to the lumen, measure length of line from skin to first hub, ensure lines and fluid bag with medications are labelled clearly, aspirate and flush any lumen that is free from any lines to check patency.