Student-Peds ALL Unfolding case study PDF

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Acute Lymphoblastic Leukemia (ALL)

April Peters, 10 years old

Primary Concept Cellular Regulation Interrelated Concepts (In order of emphasis) 1. Infection 2. Perfusion 3. Clinical Judgment 4. Thermoregulation 5. Communication 6. Collaboration 7. Patient Education

© 2016 Keith Rischer/www.KeithRN.com

UNFOLDING Reasoning: STUDENT

Acute Lymphoblastic Leukemia History of Present Problem: April Peters is a 10-year-old female with acute lymphoblastic leukemia (ALL) who presents to the emergency department with a temperature of 38.4 degrees C. (101.2 F.) and a complaint of a sore throat. She has been receiving chemotherapy since her diagnosis three months ago. April’s mother reports that her fever has been unresponsive to acetaminophen and she is two days out from her most recent chemotherapy treatment. No reports of nausea, vomiting, or diarrhea noted. A CBC is drawn immediately from April’s central venous access device (CVAD) and April is admitted directly to the pediatric oncology unit where you are the nurse responsible for her care. She weighs 57 lbs. (25.9 kg), is 51.5 inches (128.8 cm.) and has NKDA.

Personal/Social History: April lives at home with her mother Cindy, her father Tom, and her 6-year-old sister Maggie. Tom works full-time as an engineer while Cindy stays home with the children because of April’s diagnosis and resulting hospitalizations and treatment. April has missed quite a few days of school. Although her school system has provided April with a tutor to keep up with her studies, April does not return telephone calls from her friends and refuses their visits.

Past Medical History (PMH): • • •

Cindy’s pregnancy was uneventful and April was born via an uncomplicated vaginal delivery at 40 weeks and weighed 7 lbs., 1oz. (3.2 kg.) Tonsillectomy at 3 years old under general anesthesia. ALL diagnosis 3 month ago following a short history of headaches and pallor. April’s WBC count at diagnosis was 469,000  FYI: Hyperleukocytosis is defined as a peripheral white blood cell count greater than 100,000/mm3 and is a pediatric oncologic emergency. These white blood cells are immature blast cells not normal cells. Hyperleukocytosis can progress to capillary obstruction, microinfarction, and organ dysfunction, which can lead to respiratory distress and cyanosis. Children may also experience changes in neurologic function, including an altered level of consciousness, visual disturbances, confusion, and ataxia.

What data from the histories is RELEVANT and has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: - It is a disease of malignancies affecting BM and other lymphatic Diagnosis with ALL Temperature of 38.4 C or 101.2 F and fever system. Can be fatal is unresponsive to acetaminophen - Possible infection and it can be serious due to her chemo Sore throat treatment and suppressed immune system Receiving chemotherapy, starting 3 months - Infection and it needs to be treated with antibiotics before it ago progresses into complication such as rheumatic fevers. - Chemotherapy suppresses immune system.

RELEVANT Data from Social History: Frequent hospitalization and treatments Missing days of school April is withdrawing from her friends and refusing their visits

© 2016 Keith Rischer/www.KeithRN.com

Clinical Significance: - It causes physical and emotional stress r/t treatments and hospitalization - Missing school can cause emotional distress since she is school age and a sense of accomplishment is gained through school and peer by working together. Feeling of losing control - She is starting to emotionally withdrawn.

1. 2. 3. • • •

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect.) PMH: Home Meds: Mechanism of Action Nursing Considerations Leukemia -competitively inhibits dihyropteroate - may cause renal damage, SJ Sulfamethoxazolesyndrome, N/V, rash, synthase and this inhibitions of pathway Chemotherapy agranulocytosis, aplastic anemia prevents the synthesis of Chemotherapy side or phlebitis contraindicated tetrahydrofolate and ultimately prevent effects: with sulfa allergies - monitor the synthesis of bacterial purines and Constipation CBC, I&O, - drink plenty of DNA, resulting in bacteriostatic effect. Nausea fluid. Fever/comfort Trimethoprim -it binds to dihydrofolate reductase and reduction of dihydrofolic acid to - same as sulfamethoxazole tetrahydrofolic acid (THF). This reduction of THF synthesis inhibits bacterial DNA synthesis -It reduces the secretion of gastric acid Ranitidine by reversibly binding to histamine - administer with meals and at receptors found on gastric parietal cells. bedtime, assess abdominal pain, monitor for blood in stool, and -It is an anionic surfactant and lower the CBC Docusate Sodium - discontinue if cramping, rectal surface tension at the oil-water bleeding, or N/V occur, interface of the feces, allowing water administer alone for better and lipids to penetrate the stool and absorption soften the stool. - it is serotonin5-HT3 receptor Ondansetron - patient should avoid OTC cold antagonists and blocks the serotonin medications, assess lung sounds action, which results in prevention of and maintain adequate fluid nausea and vomiting. intake - it is an alkylating agent of the nitrogen Cyclophosphamide mustard type 2, It’s activated forms bind - Instruct patient to report or to DNA, resulting in cytotoxic effects by seek medication for fever or disrupting the crosslinking of DNA and other indications for infection, RNA and inhibition of protein synthesis. common side effects are N/V, loss Methotrexate of appetite, stomach pain, diarrhea, hair loss, change in skin color and nails, place - it is a pyrimidine analog and converted patient in protective isolation during hospitalizations Cytarabine into the triphosphate form from within the cell and competes with cytidine and - Monitor I&O due to side effects as N/V and loss of appetite and disrupt the DNA synthesis by hindering diarrhea, place patient in the rotation of the DNA molecule. protective isolation due to their - it reduces the prostaglandins suppressed immune system and Acetaminophen production, which is the chemical instruct the patient to report s/s responsible for inflammation and of infection swelling. - do not exceed 4g per day to reduce the risk of liver, renal and cardiac damage, overdose result in hepatotoxicity. Alter blood © 2016 Keith Rischer/www.KeithRN.com

glucose measurements and increases the risk for bleeding.

Patient Care Begins: Current VS: T: 100.8 F/38.2 C (oral) P: 112 (reg) R: 24 (reg) BP: 102/66 O2 sat: 96% on room air

P-Q-R-S-T Pain Assessment (5th VS): “My throat hurts” Provoking/Palliative: “Bad” Quality: Throat Region/Radiation: “I don’t know.” Severity: Ongoing Timing:

What VS data are RELEVANT that must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: - Indication of infection - Temp 100.8 F - Pulse 112 - Indication of pain - Painful throat - Indication of pain

Current Assessment: GENERAL Resting in bed with eyes closed, pale in appearance. APPEARANCE: RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort CARDIAC: Skin is pale, cool to touch. Cap. refill 3-4 seconds in both hands. No edema noted, heart sounds regular with no abnormal beats, radial and pedal pulses present and strong. NEURO: Patient appears lethargic, drowsy, oriented x4 GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants. Last BM yesterday evening GU: Voiding without difficulty. SKIN: Skin integrity intact. Central venous access device (CVAD) in place, dressing intact What assessment data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: - Due to chemotherapy, patient is experiencing fatigue and lethargy - Lethargic, drowsy - Possible anemia, due to chemotherapy - Pale and cool to touch cap refil 3-4

Lab Results: What lab results are RELEVANT and must be recognized as clinically significant by the nurse? © 2016 Keith Rischer/www.KeithRN.com

Complete Blood Count (CBC:) WBC (4.5–11.0 mm 3) Hgb (12–16 g/dL) Platelets (150-450 x103/µl) Neutrophil % (42–72) Band forms (3–5%)

Current: 0.2 7.4 54 1 0

High/Low/WNL?

Previous: 0.3 8.2 61 0 0

What lab results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: - Due to chemotherapy, patient is experiencing Worsening conditionings. WBC 0.2 neutropenia, leukopenia, anemia, and Hgb 7.4 thrombocytopenia. She is at high risk for Platelet 54 infection due to her suppressed immune Neut 1 system.

Basic Metabolic Panel (BMP:) Sodium (135–145 mEq/L) Potassium (3.5–5.0 mEq/L) Glucose (70–110 mg/dL) BUN (7–25 mg/dl) Creatinine (0.6–1.2 mg/dL)

Current: 130 3.5 70 26 1.4

High/Low/WNL?

Previous: 129 3.3 82 17 1.1

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: BUN 26, Creat 1.4 - Acute lymphocytic leukemia can have - Worsening effects on kidney function due to (high) increased proliferation of lymphocytes Sodium (130 – low) -

and residing in the kidney, causing tissue necrosis Due to impaired kidney function and her sore throat she is experiencing electrolyte imbalance

Misc. Labs: Magnesium (1.6–2.0 mEq/L) Ionized Calcium (1.05–1.46 mmol/L) Amylase (25–125 U/l) Lipase (3–73 units/L) Lactate (0.5–2.2 mmol/L) Coags: © 2016 Keith Rischer/www.KeithRN.com

Current: 1.9 1.05 29 27 1.8

High/Low/WNL?

Previous: 2.0 1.11 31 39 1.7

PT/INR (0.9–1.1 nmol/L)

0.9

0.9

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Misc. labs (Mg, Ionized calcium, amylase, lipase, Appears to be in WNL lactic acid, PT/INR)

Liver Function Test (LFT:) Albumin (3.5–5.5 g/dL) Total Bilirubin (0.1–1.0 mg/dL) Alkaline Phosphatase male:

Current: 3.5 1.0 75

-

High/Low/WNL?

Stable

Previous: 3.9 0.9 79

38–126 U/l female: 70–230 U/l

ALT (8–20 U/L) AST (8–20 U/L)

22 29

20 21

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: - Increase liver enzyme indicating that liver Worsening ALT 22 U/L, AST 29 function is affected by leukemia and U/L chemotherapy

Urine Analysis (UA:) Color (yellow) Clarity (clear) Specific Gravity (1.015-1.030) Protein (neg) Glucose (neg) Ketones (neg) Bilirubin (neg) Blood (neg) Nitrite (neg) LET (Leukocyte Esterase) (neg) MICRO: RBC’s ( 100.4 F. (38.0 C.)

Rationale: Fluid is first because we want to make sure that patient is well hydrated and it also help to flush out the infection. Acetaminophen is to control the infection, which in her case can be fatal due to her leukemia. Ceftrixone is next because we want to treat the infection. Vital sign is to monitor the treatments and care provided for the patient.

Ceftriaxone 75mg/kg IV every 24 hours.

Additional Pediatric Dosage Calculations: 1. Convert most recent weight from pounds to kilograms: 25.9 kg © 2016 Keith Rischer/www.KeithRN.com

2. 0.9% NS @ 20 mL/kg bolus over 60 minutes. Bolus amount: 10mL 3. IV maintenance @ 2 mL/kg/hour. Maintenance rate: 2 x 25.9 = 51.8 mL/hr 4. Ceftriaxone 75 mg/kg IV every 24 hours. Calculate dose to be given: 75 x 25.9 = 1942.5 mg/day 5. Vancomycin 15 mg/kg/day, divided q6h. Calculate dose to be given: 15 x 25.9 = 388.5 mg/day or 97.1 mg/Q6hr

Collaborative Care: Nursing 3. What nursing priority(ies) will guide your plan of care? (if more than one, list in order of PRIORITY) Priority is to control and treat the infection (antibiotics, fluids, antipyretics)

4.

What interventions will you initiate based on this priority? Nursing Interventions: Rationale:

- antibiotics (ceftriaxone, vancomycin, etc.) - antipyretics (acetaminophen)

- to treat the infection and clear the infection - to reduce fever and inflammation

- IV fluids

- to maintain proper hydration and improve electrolyte status. - to control the infection

- patient education on recognizing infection s/s and to seek immediate medical attention due to suppressed immune system - nutrition consult

- to make sure that patient is receiving adequate nutrition

Expected Outcome: - no infection - temperature is WNL and reduced inflammation and pain - No infection

- proper weight percentile

5. What body system(s) will you most thoroughly assess based on the primary/priority concern? Skin assessment, mucosal assessment, Vital signs, lung and heart sounds, GI assessment 6.

What is the worst possible/most likely complication to anticipate? Uncontrolled infection leading to death due to multiple organs failure.

7.

What nursing assessments will identify this complication EARLY if it develops? Vital signs, Skin assessment, labs (such as lactic acids or blood culture)

8.

What nursing interventions will you initiate if this complication develops? Fluids, antibiotics, antipyretics, comfort measures, protective precautions, seizure precautions, frequent neuro assessmen

9. What psychosocial needs will this patient and/or family likely have that will need to be addressed? Emotional and physical supports for both parents and the patient. Patient is in school age so school projects and friends are important. Therefore, visitations whenever possible will help improve their psychosocial interactions and uplift their spirit. 10. How can the nurse address these psychosocial needs? The nurse can address the psychosocial needs by allowing visitors whenever possible, after screening for infection signs from th visitors, allow school work in the hospital to make them feel like they are accomplishing something.

© 2016 Keith Rischer/www.KeithRN.com

Evaluation: Two hours later… All orders have been implemented, including blood cultures, medications, and IV fluid orders. April is sitting up in her bed visiting with her mother. Evaluate April’s response to the nursing and medical interventions implemented during your shift: Current VS:

Most Recent VS:

T: 37.3 C. (99.1 F.) (oral) P: 104 (reg) R: 20 (reg) BP: 102/80 O2 sat: 97% on room air

T: 38.8 C. (101.8 F.) (oral) P: 132 (reg) R: 24 (reg) BP: 82/46 O2 sat: 96% on room air

RELEVANT VS Data: Temp. 37.2 C (decreased) Pulse 104 (decreased) RR 20 (decreased and WNL) Pain scale is also reduced

Current PQRST: Provoking/Palliative: “My throat feels a little better.” Quality: Region/Radiation: Severity: Timing:

“Hurts” Throat “Not as bad.” “Off and on.”

Clinical Significance: - The treatments and interventions controlled the infections, corresponding to the reduced fever, pulse and respiration. Patient is feeling less pain and in better mood.

Current Assessment: GENERAL Sitting up in bed, interacting with mother, appears in no acute distress APPEARANCE: RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort CARDIAC: Skin is pale, cool to touch. Cap refill 2 seconds in both hands. No edema noted, heart sounds regular with no abnormal beats, radial and pedal pulses present and strong. NEURO: Awake, alert, and oriented to person, place, time, and situation (x4). GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: Voiding without difficulty, 200 mL in last 2 hours, able to ambulate to toilet SKIN: Skin integrity intact. CVAD in place, dressing intact RELEVANT Assessment Data: Sitting up in bed, appeared to be less stressed. Improved Cap refill time

© 2016 Keith Rischer/www.KeithRN.com

Clinical Significance: - Patient appearance to be in less stress, emotionally and physically. Patient is also interacting with family members, showing better psychosocial behavior.

1. Has the status improved or not as expected to this point? Situation is improved and the patient appears to be relaxed. 2. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? Continue to monitor closely for infections, the effects of antibiotics and their side effects and hydration status. 3. Based on your current evaluation, what are your nursing priorities and plan of care? Continue to finish the course of antibiotics and monitor temperature closely.

It is now the end of your shift. Effective and concise handoffs are essential to excellent care. A poor or incomplete handoff can adversely impact April’s care. You have done an excellent job to this point. Now finish strong and give the following SBAR report to the nurse who will be caring for this patient:

Situation: Name/age: April Peters, 10 y/o female BRIEF summary of primary problem: She came into the ER complaining of sore throat. Patient was diagnosed with leukemia 3 months ago. Her mother states that she has a fever of 102 F and has not been responsive to acetaminophen.

Background: Primary problem/diagnosis: Sore throat secondary to acute lymphoblastic leukemia. RELEVANT past medical history: Patient was diagnosed with acute lymphoblastic leukemia 3 months ago and receiving chemotherapy. She is often out of school due to her chemo treatment. RELEVANT background data: Patient is catching up school work with tutors but missing school and withdrawing from friends and refuse to let them visit. .

Assessment: Most recent vital signs: Temp 100.8 F, Pulse 112, RR 24, BP 102/66, O2 sat 96% at RA. Bad Throat pain that is ongoing,

RELEVANT body system nursing assessment data: Resting in bed with eyes closed, pale in appearance, breath sounds are equal and clear, not labored, skin is cool to the touch. Cap refill is 3-4 seconds, No edema, heart sounds are regular, pulses are strong and regular, A&O x4, No N/V. Abdomen is nontender with audible vowel sounds, voiding urine easily. Skin is intack. CVAD is in place, intact and dressing is dry. © 2016 Keith Rischer/www.KeithRN.com

RELEVANT lab values: WBC 0.2, Hgb 7.4, platelet 54, neutrophils 1%, no bands, ALT 22 U/L and AST 29 U/L. Amber color urine and clear. SG is 1.042, BUN 26, Creat 1.4 (high), Sodium (130 – low) TREND of any abnormal clinical data (stable-increasing/decreasing): Patient’s CBC values are dangerously low and all other lab values are worsening. How have you advanced the plan of care? The provider admitted her to the pediatric oncology units, weighing daily, strict I&O, Gave her 0.9% NS bolus at 20 mL/kg over 60 mins at 0800 and now she is on D5.45 NacL with 20 mEq/L KCl at 2 mg/kg/hr. vital signs every 2 hours and as needed. Gave Acetaminophen 5mL PO at 0800 and Q4hr after for fever > 100.4 F. Ceftriaxone 75mg/kg IV every 24 hours, Obtained rapid throat culture and waiting on the result. She also has prescription for Vancomycin 15 mg/ kg/day Q6H. Patient response: After giving the medication, her temperature is now at 99.1 F, P 104, RR is 20, BP 102/80 and patient states that her throat is feeling a little better. She is also sitting up in the bed and interacting her mom. INTERPRETATION of current clinical status (stable/unstable/worsening): Patient is stable.

Recommendation: Suggestions to advance...