C.O. is a 43-year-old woman who noted a nonpruritic nodular
rash on her neck and chest about 6 weeks ago. The rash became
generalized, spreading to her head, abdomen, and arms, and was
accompanied by polyarticular joint pain and back pain. About 2
weeks ago, she experienced three episodes of epistaxis in 1 day.
Over the past week, her gums became swollen and tender and she was
severely fatigued. Because of the progression of symptoms, she
sought medical attention. Lab work was done, and C.O. was directly
admitted to the hematology/oncology unit under the care of a
hematologist for diagnostic evaluation. Skin biopsy showed
cutaneous leukemic infiltrates, and bone marrow biopsy showed
moderately hypercellular marrow and collections of monoblasts. Her
lumbar puncture specimen was free of blast cells. The final
diagnosis was acute myeloblastic leukemia.
C.O. is to begin remission induction therapy with cytarabine
100 mg/m2/day as a continuous infusion for 7 days and idarubicin 12
mg/m2/day IV push for 3 days. She is scheduled in angiography for
placement of a triple-lumen subclavian catheter before beginning
her therapy.
Laboratory Test Results
Complete Blood Count (CBC)
White blood cells (WBCs) 39,000/mm3 (39 x 109/L)
Monocytes 64%
Lymphocytes 15%
Neutrophils 4%
Blasts 17%
Hemoglobin (Hgb) 10.4 g/dL (104 g/L)
Hematocrit (Hct) 28.7%
Platelets 49,000/mm3 (49 x 109
CASE STUDY PROGRESS
On the ninth day of continuous infusion of chemotherapy, the
UAP reports C.O.’s vital signs to you.
Vital Signs
BP 110/54 mm Hg
Heart rate 115 beats/min
Respiratory rate 26 breaths/min
Temperature 101.6° F (38.7
CASE STUDY PROGRESS
Your assessment findings are unremarkable and you notify the
intern on call of C.O.’s vital signs. After evaluating C.O., the
orders shown in the chart are written.
Physician’s Orders
Blood cultures now × 2 sites
CBC with differential now
Acetaminophen suppository 650 mg q4-6h prn
Imipenem/cilastatin sodium 500 mg IV piggyback q8h
Notify hematologist for temp over 100.0° F (37.8° C)
7. Do these orders seem appropriate? Explain.
8. What will your next action be?
Laboratory Test Values
WBCs 1200/mm3 (1.2 x 109/L)
Monocytes 25%
Lymphocytes 65%
Neutrophils 5%
Blasts 5%
Bands 0%
Hgb 6.8 g/dL (68 g/L)
Hct 21.3%
Platelets 17,000/mm3 (17 x 109/L)
9. What do these laboratory values indicate about her immune
system?
10. Considering the previous data, what blood products will
most likely be given to C.O.?
CASE STUDY PROGRESS
With continued blood product support and antibiotic coverage,
C.O. is able to complete 14 days of therapy and a bone marrow
biopsy shows she is in complete remission. HLA typing has been done
on all her siblings. Her oldest brother is a perfect HLA match and
has agreed to donate bone marrow. C.O. is being discharged with
plans to readmit her to the bone marrow transplant unit within the
next few weeks.
11. What does “complete remission” mean for C.O., and what
effect did it have on the decision to perform a bone marrow
transplant?
12. What type of bone marrow transplant will she have? Briefly
describe this transplant process.
13. Name 4 priority problems C.O. will face in undergoing a
bone marrow transplant. Put a star next to the most important
priority
14. What is the most important intervention
post-transplant?
A. Giving analgesics for postprocedural pain
B. Monitoring for signs of infection and bleeding
C. Weighing her daily and offering small, frequent meals
D. Offering emotional support to C.O. and her family during
recovery
15. What type of isolation will C.O. need? Outline the
guidelines for maintaining this type of isolation.
16. Undergoing a bone marrow transplant is challenging.
Describe how you would provide emotional support to C.O. and her
family.
17. Name 3 complications C.O. will be at risk for after the
transplant.
18. Describe graft-versus-host disease.
19. True or false. If the transplanted cells do not engraft,
C.O. will die unless another transplant is tried and successful.
Defend your response.