INTRODUCTION

Chronic Myeloid leukemia accounts for approximately 14% of all cases

of leukemia the incidence in about 4600 cases per year. the frequency of CML
increase with age from 40 to 50 years. It is uncommon in people younger than 20
years of age once CML in diagnosed the client have an overall survival time
rarely exceeds several months

CML arise from the mutation in the myeloid stem well. Normal myeloid
all are produced abnormally as immature blast from. so CML in the neoplastic
proliferation of one particular cell type that is the myeloid stem wells

When I was working in male medical ward 105 Mr. Sappani was admitted
with the diagnosis of CML. So I have selected this client for my case
presentation in order to study the disease condition in detail
 OBJECTIVES
 To establish rapport with the client and his family members
 To do complete health assessment of the client and to understand about
his health condition
 To identify the Nursing needs of the client
 To acquire knowledge and understanding about chronic myeloid
leukemia
 To formulate Nursing diagnosis for client with chronic myeloid
leukemia
 To give comprehensive nursing care for the client with chronic myeloid
leukemia
 To provide health education about the importance of good nutrition and
adequate fluid intake and to do meticulous oral care
 PATIENT PROFILE
Name of the client : Sappani

Age : 45y

Sex : Male

Ward : 105

Unit : VII

MRD. No : 1075752

Marital Statius : Married

Educational Qualification : 5th std

Religion : Hindu

Occupation : Cooly

Family Income : Ro.900/month

Address : S/o karuppaiah

Nethaji Nagar

Rameswaram

Source of informant : Wife

Date of admission : 4/10/15 at 1.50pm

Medical diagnosis : Chronic myeloid leukemia

Reason for admission : Patient complaints of severe fatigue,

bilateral, hearing loss and mild fever. &

pain in bone
 HISTORY
HISTORY OFPRESENT ILLENSS

Patient, had bilateral hearing loss, lost his hearing ability in his both ears
and he became easily fatigue since one month. Had vomiting two to three
episodes 15days back and had pain in the bones with mild fever. So patient got
admitted in the medical ward for treatment Now patient is having blurred Vision
and pain in the bones

PAST HEALTH HISTORY

Patient had no history of systemic hypertension and pulmonary

tuberculosis. He had type II diabetic since 3years- and he was on Tab metformin
and Tab Daonil – but now the blood sugar is normal. he had no history of having
surgical treatment, and blood transfusion, Doest have any history of allergies to
drugs and exposure of STDS

No 14/9/15 patient had giddiness and was admitted in Ramanathapuram

head quarters hospital and was treated with inj ampicilline Tab. Ramitidine and
T. Paracetamol. Since the CT brain in normal got discharged from the hospital on
21/9/2015

FAMILY HISTORY

He belongs to Nuclear family. Family members remains normal and

doesn`t have any risk factors. His family members doesn`t have any history of
having cardiac disease, hypertension, Jaundice, mental linens, congenital,
abnormalities, communicable disease. His younger daughter is mentally retarded
his younger brother had diabetic mellitus
GENOGRAM

45yr 40yrs

25y

Socio Economic History

Type of house - Thatched house

Own /rented - living in their own house

Water facility - Taking water from municipal pipe and using

Drainage facility - has proper closed type of drainage system

Cross Ventilation - Adequate Has enough windows and doors.

Disposal refuse - Disposing the refuse by dumping

Lighting facility - Has electricity facility

Pet animals - Has no pet animals but has domestic animal cow

Garden - No space for keeping garden.

Economic status is poor - heis working as a cooly worker monthlyincome

isRS900
PERSONAL HISTORY
Place of birth - kamuthi, vedankottam

personal experience at different age in uneven full. Has good relationship with
his friends relatives neighbours and with his siblings

He belongs Hindu religion He goes to temple on Fridays if time permits- He

speaks Tamil and understand Tamil alone. Taking mixed diet Had anorexia since
1½ months and insomnia since 2months He watches TV and his hobby is
watching TV –He is a chronic smoker. He doesn`t have any history of taking
alcohol and abusing drugs.

MARITAL HISTORY
Got married at the age of 23, not a consanguineous marriage, he is happily
living with his wife and children

PHYSICAL ASSESSMENT HEAD TO FOOT ASSESSMENT

Head and scalp - Normal, and scalp clean
Hair - Blackish grey, poorly groomed
Eyes - slightly jaundiced, conjunctiva looks pallor Right eye
has vitreous heamorrage & left eye has diabetic
retinopathy as well as leukemic retinopathy
Mouth lips - dry
oral mucosa - looks pallor, no ular
Tongue - coated
neck - No lymph nodes visible and palpated
chest - Looks skin and bony, ribs visible symmetrical,
Having dyspnoea and using acessary muscles for
respiration Having tenderness in the sternum
Abdomen - Enlarged, tensed, Abdominal veins are visible, has
massive splenomegaly and moderate hepatomegaly
Back - Has back pain
Lower extremities - Pedal edema present - increased in left lag
Has good relationship with his friends relatives neighbours and with his
siblings He belongs to Hindu religion and goes to temple if time permit on
Friday. he speaks Tamil and understood Tamil alone. takes mixed food had good
sleep but since 1½ months if in not adequali - He watches TV. He is a chronic
smoker- doesn’t aboue any drug

ARITAL HISTORY

Got married at the age of 23 not a consanguineous marriage

SYSTEMIC REVIEW
Central Nervous : patient is conscious, oriented looks dull and apathy

lost his hearing ability

Respiratory system : Observation. R.R.30 to 38 / little dysphnoeic

chest symmetry is normal, looks skin and bony
chest movement normal on breathing, Having no
cough - wring accessory muscles for respiration.

Auscultation : Bilateral vesicular breath sounds audiable

Percussion : Resonance normal having sterna tenderness.

CARDIO VASCULAR SYSTEM

Inspection : JVP not elevated – carotid pulsation present

Palpation : Pulse 100/mt , volume and tension fair-no

abnormalities

Auscultation : Heart sounds normal –No murmur

Percussion : Resonance Normal

GASTRO INTESTINAL SYSTEM
Inspecting : Abdomen looks enlarged, tensed, visible veins present No
visible surgical scar
Palpation : Massive splenomepaly and moderate Hepatomegaly presents
Auscultation: Bowel sounds in all four quadrants normal
Percussion : No fluid thrill
Gastrointestinal system Bowel movement – Regular onetime in a day.
MUSCULO SKELETAL SYSTEM
Looks skin and bony, range of motion normal No congenital abnormalities
‘ No Shortening of Limbs No Paresis and Paralysis Havking pain in the joints and
in bones
ENDOCRINE SYSTEM
Patient is a known case of diabetes mellitus. But presently, Blood sugar
level is normal. 73mg /d1
LYMPHATIC SYSTEM
There is no generalized Lymphadenopathy, but, having bilateral, inguinal
lymphangitis
GENITO –URINARY SYSTE
Bladder movement normal, passing urine normally output per day is
around, 1400ml/day. In take and output chart maintained
INTEGUMENTARY SYSTEEM: Having abnormal temperature –had mild
degree of fever initially. on assessment temperature normal skin turgor is poor no
signs of inflammation, pigmentation and paresthesia.
VITALSIGNS
Temperature : 990 F

Pulse : 100/mt

Respiration : 24to,36/tm, attimess dysponeic

Blod pressure : 130/80mm of hg

Pain : Having pain in the bones and a severe in the

sternum and inguinal region. Has bilateral

inguinal lymphadenitis

O2 satiation : 92%
DIAGNOSTIC INVESTIGATIONS
Type of Investigation Patient value Normal value Remarks

1.Blood urea 20mq/d1 15/40mq/d1 Normal

2. Sr.Creatinine 0.7mq/d1 0.6-1.5mq/d1 Normal

3. Serum electrolytes
sodium 130meq/lit 135-145mq/lit Reduced
potassium 3.6 meq/lit 3.5 to 5,meq /lit Normal
chloride 101 meq/lit

4. Total bilirubin 1.5mq/d/ 0.2 to 1mq/d

Direct 0.6 mq/d1 0.4 mq/d Increased
Indirect 0.9 mq/d1 0.6 mq/d a little

Opinions: Opthalmologist opinion

Right eye - Vitreous hemorrhage

Left eye - Features of diabetic retinopathy and leukemic retinopathy

Type of Patient value Normal value Remarks

Investigation
SGOT 96 1u/L 5-45 1u/L Increased

SGPT 20 1u/L 5-40 1u /L Normal

ALP 12 11u/L 3-13 1u/L Increased

Total protein 1.5 g/d1 6-8g/d1 Decreased

 Seem albums 3.2 g/d1 3.5-5g/d1 Decreased

Serum globulin 1.2 g/d1 2.5-3.5g/d1 Decreased

HB 9.5.repeated 10to 13 gms Anemia

6.gm
TC 270,000 1u/mt 55 to 10.5 Heyperleukocytosis
cu/mt
Total WBC 661000 cells / 4500 -11000/ Increased
count cumm cumm
Platelet 1.32 L. 1 lash 2 to 3.5 lakhs / Decreased
1.28laks cumm
Urine –albumin One + Nil Abnormal

Sugar Nil Nil Normal

Deposit 4 to 5 cetin Nil Considered as

Normal
Blood sugar 73mg/d/ 80 to 12mg/d/ Normal

USG – Massive Normal size In flammced

Abdomen Splenomegaly Normal size
Moderate In flammed
Hepatomegaly
Spleen size 22
cum
`ECG – 12 lead Normal Axis Normal LVH
LVH Present
Left
ventricular
Hypertrophy
DRUG CHART

Name of Dose Rout Action Side effect Nurses Role

the drug e Dizziness
Inj.ceftriaxo 1g BD IV Antibiotics Head ache Observe for
ne inhibits fatigue side effects
bacterial
cell wall
synthesis
T.Ranitine 150m Oral Reduces the Skin Observe for
g tds gastric acid rashes side effects
secreation Nausea
H2ion vomiting
antagonist
T.Domstal 1 od Oral antiemetics Head ache Observe for
drowsiness giddiness
T.Paraceta 500m Oral anti pyretits Skin Watch for
mol g Bd sashes side effect
hypotherm cheek
ia temperature
Iv fluid 1000 IV Intravenous Overload Maintain
normal ml fiuid causes fluid
Saline pulmonary intravenousl
2pints oedema y

ANATOMY AND PHYSIOLOGY

WHITE BLOOD CELLS

These cells have an important function in defense and immunity. They detect
foreign or abnormal material and destroy it ,m through a range of defence mechanism
 Leckoc are the largest blood cells but they account for only about 1% of the
blood volume. They contain nucler and some have granules in their cytoplasm. There
are two main types

1. granulocytic (polymorph nuclear leukocytes)

neutrophile, eosinophils and basophiles
2. A Granulocytes mono cytes and lymphocytes

Rising white cell numbers in the blood stream, usually indicate a physiological problem
(g) infection trauma or malignancy

GRANULOCYTES

During their formation granulopoiesis in they follow a common line of

development through myeloblst, to monocytes before differentiating into three types

All granulocytes have multilobed nucles in their cyto plasm, Eosinophil takes
red aid dye leosin, and basophil take alkaline methylated blue and neutrophil are purple
because they take both dyes

NEUTRO PHIL
These small, fast and active scavenger protect the body against bacterial invasion
and remove dead cells and debris from damaged, tissues. They are highly mobile and
squeegee through the capillary walls in the affected area by diapedesis. The numbers
rise very quickly in an area of damaged or infected tissue They engulf and kill bacteria
by phagocytosis

EOSINOPHIL

Capable of phagocytosis but less active than neutrophil they are equipped with certain
toxic chemical, store in their granules which they release when the eosinophils binds to
an infecting organism.
BASOPHIL

Closely asocial with allergic section contain cytoplasmic granules packed with
heparin, histamine and other substances that promote inflammation

GRANULOCYTES

MONOCYTES

There are Largest WBC some circulate in the blood and are actively motile, and
phagocytic while others migrate into tissues where they develop into macrophages It
acts on the hypothalamus causing rise in the body temperature associated with
microbial infection stimulates the production of so some globulin by the liver enhancer
the production of activate T. lymphocytes

LYMPHOCHTES

They are smaller than monocytes and have large nuclei some criculales in the
blood and some found in the tissue including lymphatic tissue such so lymph nodes and
the spleen. lymph ocytes develop from pluripotent stem cells in the red bone marrow
and from precursors in lymphoid tissue Although all lymphouytes originate from only
one type of stem cell the final step in their development lead to the production of two
lymphocytes
DISEASE CONDITION

DEFNITION

Chronic myeloid leukemia is a Neoplastic proliferation of myeloid cells which

produces immature blast cells resulting bone Marrow expansion enlargement of spleen
and liver, and produces hemopoietic malignancies.
ETIOLOGY

An accquired injury to DNA of a stem cell in the bone Marrow

And this injury is not inherited, not present at birth

PATHOPHYSIOLOGY

Mutation in the myeloid stem cell occurs

Increases the proliferation of immature blast cells

Number of circulating granulocytes increases

Marrow expants into the cavities of long bone (eg) femur

At the same time cells formed in lives and spleen(extramedullary hemato

poises)

Enlargement of spleen and liver

Enlargement of organ (pain, fatigue, anorestia,)

Blost crisis

Survival for few months only

HOW THIS MUTATION OCCURS

In DNA Chromosome 22 will be missed (Philadelphia chromosome ph1)

Chromosome 22 will be translocated on to chromosome 9

The specific location is on the BCR gene of chromosome 22 and ABL gene of
chromosome 9
 When these two gene fuse (BCR –ABL gene)

Produce abnormal protein)

(tyrosinekinse protein)

Causes WBCS to divide rapidly

This causes mutation

STAGES IN CML
1. Chronic stage
2. Transformation
3. Accelerated on blast crisis
1. CHRONIC STAGE

CML commonly changes from a chronic indolent phase into an accelerated

phase that progresses rapidly into a fulminant neoplastic process

Sometimes indistinguishable from an acute leukemia

2. ACCELERATED PHASE (blaotic phase)

The accelerated phase of he disease is characterized by increasing number of

granuoajtes in the blood peripheral blood often corresponding anemia and theromboyto
penia fever and adenopathy also may develop

3. TRANSLOCATION PHASE It cause tramoloation of chromosome

CLINICAL MANIFESTATION

1. leukocytosis

2. Shortness of breath
 3. Slightly confused due to deceased capillary perfusion to the lungs and

brain

4. Enlarged and tender spleen

5. Enlarged liver

6. Malaise

7. Anorexia

8. weight loss

9. Lymphadenopathy in very rare

MANAGEMENT

MEDICAL MANAGEMENT

1 An oral formulation of a tyrosine kinas inhibitor I matinib mesylate (gleevec)

There drugs works by blocking signals within the leukemia cells that expresses
BCR-ABC protein thus preventing a series of chemical reaction that cause the cell to
grow and divide

2 . Antacids and grape fruit juice limit drug absorption

3 Acetaminophen

4. Combination of cytosine and interferon alfa

5. Chemotherapeutic agents (g) heftshydroxyurea and busulfan Daunomyuin

6. Bone marrow transplantation

NURSING AIAGNOSIS

1. Acute pain and discomfort seated to WBC infiltration of systemic

tissues and bone marrow
 2. Imbalanced nutrition less than body requirements related to hyper
metabolic state, anorexia pain, nausea and vomiting
3. Fatigue and activity intolerance related to Anemia and infection
4. Impaired physical mobility due to anemia and bone pain
5. Disturbed body image related to change in appearance function and
role
6. Anxiety due to knowledge deficit and uncertain future
7. Grieving related to anticipatory loss and altered role functioning
8. knowledge deficit about disease process, treatment and
management
9. Risk for infection as bleeding
10.Risk for impaired skin integrity related to alteration in nutrition and
impaired mobility
11.potential for spiritual distress
12.self care deficit due to fatigue and malaise
13.Impaired gas exchange seated to the infiltration of malignant cells
in lungs

NURSING PROCESS
SUBJECTIVE DATA : The client verbalizes that he is having pain in
bones
Subjective data : The client looks discomfort and restless. Nursing
Diagnosin : Acute pain related to WBC infiltration of
systemictissues and bone marrow

Goal : To alleviate the pain and makes the patient

Comfortable
Plan of Implementation Rationale Evaluation
Action
Establish Established Gained co-
rapport with rapport with operation of the
client and his client and her client & family
family family members members
members Assessed the
condition of pain- Helps to
Assess the pain the bones identify the
characteristics severe in intensity condition of the
of pain, client and to
quality understand the
intensity infilteration of
blost blurt cells
Vital signs into the cavity
monitored T.990F, of bones
pulse 100/mt
RR.38/mt Provide the
Monitor the information
vital signs Provided division about
therapy by hemodynamic
allowing the status
client to have a
spiritual Create a
Provide discussion with relaxation in the
diversion relatives mind
therapy
Provided a calm
and conducive
environment by
mininizing the Still
noise, allowing Creatte further having
Provide a cross ventilation relaxation in pain
calm well by keeping the mental status
conducive windows open
environment
Administered tab.
parautamol
according to the
 prescription of the
doctor
The
Reassessed the intensity
Administer client of pain
drugs Reduces pain reduced
maintained all the
events in the
records

Intensity
Reassess the Provide of pain got
client information reduced
about pain
maintain
records and Legal justiu
reports

SUBJECTIVE DATA : Patient verbalizes that his nutritional in take is

reduced and having vomiting
Subjective data : Patient doesn’t eat well eat a little and having
Vomiting
Nursing diagnosis : Imbalanced nutrition lersthan body requirement
related to hyper metabolic state and vomiting
Goal : To maintain the nutritional status

Plan of Action Implementation Rationale Evaluation

Assess the condition Assessed the Provides
of the client condition of the information about
client patient condition
Assess the skin
turgor Assessed the skin Reveals
turgor has poor information about
Encourage the skin turgor nutritional stales
patient to take small Encouraged the Provides
frequent feedings of patient to take food information about
foods in soft texture with toleration
moderate Tolerated
temperature
 (Avoided Raw
vegetables and raw
fruits those
without a peelable
skin)
Check for vomiting
Checked for
vomiting. patient Provides
had infrequent information about
Administer vomiting fluid volume
antiemetics Administered Tab.
domstal as per as
the doctor’s order Reduces vomiting
Administer IV. fluid Administered Vomiting
normal saline reduced
intravenously as Improve
per as doctors nutritional status
order
Maintain records Nutritional status
and reports Recorded all the maintained
events
Legal justice

SUBJECTIVE DATA : Patient verbalizes that he is getting very tired

Objective data : Patient looks tired and inactive
Nursing diagnosis : fatigue and activity intolerance related to Anemia
Goal : To Assist the patient to establish a balance
Between activity and rest

Planning of Implementation Rationale Evaluation

Action
Assess the Assessed the Reveals the
condition of the patient condition condition of the
patient patent

Establish a Established a Decreases the

balance between balance between fatigues
activity and rest activity and rest
by making the
patient to
ampulate out of
bed
Provide some Provided physical Deceases Able to walk
physical activity activity such as fatigues inside the room
walking inside fatigue likely to
the room decreased

Provide some Allowed the Degree of

excercise patient to Improve tidal fatigue reduced
ambulate and to volume and
sit up in a chair enhance
while awake circulation
rather than
staying in bed
Fatigul reduced
Reassess the Reassessed the able to sit in the
condition of the condition of the Provide chain
patient patient information
about fatigues
Maintain records Recorded all the
and reports events in rewrds Legal justice

HEALTH EDUCATION

REGARDING DIET
 Advices the client to take low microbial dial. Adviced the patient to avoids
uncooked fruits or vegetables and those without a peelable skin. Adviced the client
regarding the importance of good nutrition and adequate fluid intake and taking garlic
Garlic inhibit the proliferation of myeloid cells and enhance the action of antineoplastic
drugs

REGARDING ORAL HYGIENE

Educated the client to maintain meticulous oral hygiene to prevent stomatitis and
to have oral hygiene after every meals with saline orsalt or soda solution and to avoid
commercial mouthwashes.

REGARDING MEDICATION

Advised the patient to take the medications regularly. Name of the drug, dose
and its side effects and symptom of side effect

REGARDING COMMUNITY RESOURCES

Advised the client regarding the available community resources and encouraged
him to make use of it

REGARDING FOLLOW UP CARE

Advised the client regarding the need for regular medical follow up care and
symptom requiring immediate medical attention (fever, bleeding)

REGARDING PREVENTION OF INFECTION & BLEEDING

Advised the patient regarding meticulous personal hygiene and about the
precautionary methods to be adhered in the daily life inorder to prevent bleeding and
also how to control bleeding in care of expistasus.

CONCLUSION
 From this clinical presentation I had an excellant
opportunity to learn about CML I came to understand about the
need of efficient and comprehensive nursing care which helps
in the speedy recovery from the manifested signs and
symptoms.

I thank our Madam Mrs.J.Alamelu mangai M.Sc (N)

MBA Mrs.N.Rajalakshmi M.Sc(n) Nurasing Tutor GR II- for
giving me

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