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Nursing Practice Paper, APA Style (Riss)
The header consists of a shortened title in all capital letters at the left margin and the page number at the right margin; on the title page only, the shortened title is preceded by the words “Running head” and a colon.
Acute Lymphoblastic Leukemia and Hypertension in One Client: This paper was prepared for Nursing 451, taught by Professor Durham. The author wishes to thank the nursing staff of Milltown General Hospital for help in understanding client care and Marginal annotations indicate APA-style formatting and effective writing.
Source: Hacker Handbooks (Boston: Bedford/St. Martin’s, 2011, 2007).
This paper follows the style guidelines in the Publication Manual of the American Psychological Association, 6th ed. (2010).
Acute Lymphoblastic Leukemia and Hypertension in One Client: Historical and Physical Assessment
Physical History
E.B. is a 16-year-old white male 5'10" tall weighing 190 lb. He was admitted to the hospital on April 14, 2006, due to decreased platelets and a need for a PRBC transfusion. He was diagnosed in October 2005 with T-cell acute lymphoblastic leukemia (ALL), after a 2-week period of decreased energy, decreased oral intake, easy bruising, and petechia. The client had experienced a 20-lb weight loss in the previous 6 months. At the time of diagnosis, his CBC showed a WBC count of 32, an H & H of 13/38, and a platelet count of 34,000. His initial chest X-ray showed an anterior mediastinal mass. Echocardiogram showed a structurally normal heart. He began induction chemotherapy on October 12, 2005, receiving vincristine, 6-mercaptopurine, doxorubicin, intrathecal methotrexate, and then high-dose methotrexate per protocol. During his hospital stay he required packed red cells and platelets on two different occasions. He was diagnosed with hypertension (HTN) due to systolic blood pressure readings consistently ranging between 130s and 150s and was started on nifedipine. E.B. has a history of mild ADHD, migraines, and deep vein thrombosis (DVT). He has tolerated the induction and consolidation phases of chemotherapy well and is now in the maintenance phase, in which he receives a daily dose of
mercaptop urine, weekly doses of methotrexate, and intermittent
doses of steroids.
Psychosocial History
There is a possibility of a depressive episode a year previously when he would not attend school. He got into serious trouble and Source: Hacker Handbooks (Boston: Bedford/St. Martin’s, 2011, 2007).
was sent to a shelter for 1 month. He currently lives with his
mother, father, and 14-year-old sister.
Family History
Paternal: prostate cancer and hypertension in grandfather
Maternal: breast cancer and heart disease
Current Assessment
Client’s physical exam reveals him to be alert and oriented to person, place, and time. He communicates, though not readily. His speech and vision are intact. He has an equal grip bilaterally and can move all extremities, though he is generally weak. Capillary refill is less than 2 s. His peripheral pulses are strong and equal, and he is positive for posterior tibial and dorsalis pedis bilaterally. His lungs are clear to auscultation, his respiratory rate is 16, and his oxygen saturation is 99% on room air. He has positive bowel sounds in all quadrants, and his abdomen is soft, round, and nontender. He is on a regular diet, but his appetite has been poor. Client is voiding appropriately and his urine is clear and yellow. He appears pale and is unkempt. His skin is warm, dry, and intact. He has alopecia as a result of chemotherapy. His mediport site has no redness or inflammation. He appears somber and is slow to comply with nursing instructions. Medical Diagnosis #1: Acute Lymphoblastic Leukemia
Leukemia is a neoplastic disease that involves the blood- forming tissues of the bone marrow, spleen, and lymph nodes. In leukemia the ratio of red to white blood cells is reversed. There are approximately 2,500 cases of acute lymphoblastic leukemia (ALL) per year in the United States, and it is the most common Source: Hacker Handbooks (Boston: Bedford/St. Martin’s, 2011, 2007).
type of leukemia in children—it accounts for 75%-80% of childhood leukemias. The peak age of onset is 4 years, and it affects whites more often than blacks and males more often than females. Risk factors include Down syndrome or genetic disorders; exposures to ionizing radiation and certain chemicals such as benzene; human T-cell leukemia/lymphoma virus-1; and treatment for certain cancers. ALL causes an abnormal proliferation of lymphoblasts in the bone marrow, lymph nodes, and spleen. As the lymphoblasts proliferate, they suppress the other hematopoietic elements in the marrow. The leukemic cells do not function as mature cells and so do not work as they should in the immune and inflammatory processes. Because the growth of red blood cells and platelets is suppressed, the signs and symptoms of the disease are infections, bleeding, pallor, bone pain, weight loss, sore throat, fatigue, night sweats, and weakness. Treatment involves chemotherapy, bone marrow transplant, or stem cell transplant (LeMone & Burke, 2004).
Medical Diagnosis #2: Hypertension
Primary hypertension in adolescence is a condition in which the blood pressure is persistently elevated to the 95th to 99th percentile for age, sex, and weight (Hockenberry, 2003). It must be elevated on three separate occasions for diagnosis to be made. Approximately 50 million people in the United States suffer from hypertension. It most often affects middle-aged and older adults and is more prevalent in black adults than in whites and Hispanics. In blacks the prevalence between males and females is equal, but in whites and Hispanics more males than females are affected. Risk Source: Hacker Handbooks (Boston: Bedford/St. Martin’s, 2011, 2007).
factors include family history, age, race, mineral intake, obesity, insulin resistance, excess alcohol consumption, smoking, and stress. Hypertension results from sustained increases in blood volume and peripheral resistance. The increased blood volume causes an increase in cardiac output, which causes systemic arteries to vasoconstrict. This increased vascular resistance causes hypertension. Hypertension accelerates the rate of atherosclerosis, increasing the risk factor for heart disease and stroke. The workload of the heart is increased, causing ventricular hypertrophy, which increases risk for heart disease, dysrhythmias, and heart failure. Early hypertension usually exhibits no symptoms. The elevations in blood pressure are temporary at first but then progress to being permanent. A headache in the back of the head when awakening may be the only symptom. Other symptoms include blurred vision, nausea and vomiting, and nocturia. Treatment involves medications such as ACE inhibitors, diuretics, beta-adrenergic blockers, calcium channel blockers, and vasodilators as well as changes in diet, such as decreased sodium intake. An increase in physical activity is essential to aid in weight loss and to reduce stress (LeMone & Burke, 2004). Chart Review
Active Orders
Vital signs q4h
Fall precautions
OOB as tolerated
Oximetry monitoring—continuous
Source: Hacker Handbooks (Boston: Bedford/St. Martin’s, 2011, 2007).
Regular diet
Weight—daily
Strict intake and output monitoring
Type and cross match
PRBCs—2 units
Platelets—1 unit
Discharge after CBC results posttransfusion shown to MD
Rationale for Orders
Vital signs are monitored every four hours per unit standard. In addition, the client’s hypertension is an indication for close monitoring of blood pressure. He has generalized weakness, so fall precautions should be implemented. Though he is weak, ambulation is important, especially considering the client’s history of DVT. A regular diet is ordered—I’m not sure why the client is not on a low-sodium diet, given his hypertension. Intake and output monitoring is standard on the unit. His hematological status needs to be carefully monitored due to his anemia and thrombocytopenia; therefore he has a CBC with manual differential done each morning. In addition, his hematological status is checked posttransfusion to see if the blood and platelets he receives increase his RBC and platelet counts. Transfused platelets survive in the body approximately 1-3 days, and the peak effect is achieved about 2 hr posttransfusion. Though platelets normally do not have to be cross-matched for blood group or type, children who receive multiple transfusions may become sensitized to a platelet group other than their own. Therefore, platelets are cross-matched with the donor’s blood components. Blood and platelet transfusions may result in hemolytic, febrile, or Source: Hacker Handbooks (Boston: Bedford/St. Martin’s, 2011, 2007).
allergic reactions, so the client is carefully monitored during the transfusion. Hospital protocol requires a set of baseline vital signs prior to transfusion vital signs. After the blood and platelets have been given, the physician is apprised of CBC results to be sure that the client’s thrombocytopenia has resolved before he is discharged. Pharmacological Interventions and Goals
enoxaparin sodium (Lovenox) low-molecular-weight60 mg SQ bid PRBCs—2 units leukoreduced, to increase RBC countirradiateda a Because these products are dispensed by pharmacy, they are considered a pharmacological intervention, even though technically not medications.
Source: Hacker Handbooks (Boston: Bedford/St. Martin’s, 2011, 2007).
Laboratory Tests and Significance
in several tables for easy reference.
a Rationale: Client’s ALL diagnosis and treatment necessitate frequent monitoring of his hematological status. WBC count is decreased due to chemotherapy, as are RBC and hematocrit. The platelet count is low as well. a Rationale: To determine client’s blood type and to screen for antibodies.
Vital Signs Before, During, and After Blood Transfusiona a Rationale: To monitor for reaction.
Source: Hacker Handbooks (Boston: Bedford/St. Martin’s, 2011, 2007).
Nursing Diagnosis #1:
Injury, Risk for, Related to Decreased Platelet
Count and Administration of Lovenox
Desired Outcome: Client will remain free of injury.
Interventions
Assess for manifestations of bleeding such as description and rationales for each.
• Skin and mucous membranes for petechiae, ecchymoses, • Gums and nasal membranes for bleeding • Overt or occult blood in stool or urine• Neurologic changes Provide sponge to clean gums and teeth
Apply pressure to puncture sites for 3-5 min
Avoid invasive procedures when possible
Administer stool softeners as prescribed
Implement fall precautions
Monitor lab values for platelets
Administer platelets as prescribed
Measurable Outcomes
Mediport site will remain intact with no signs of bleeding.
Urine and stool will remain free of blood.
Lab values for anticoagulant therapy will remain in desired range.
Platelet count will remain in normal range.
Client Teaching
Instruct client to avoid forcefully blowing nose, straining to have a bowel movement, and forceful coughing or sneezing, all of which increase the risk for external and internal bleeding Source: Hacker Handbooks (Boston: Bedford/St. Martin’s, 2011, 2007).
Discharge Planning
Instruct client to monitor for signs of decreased platelet count
such as easy bruising, petechiae, or inappropriate bleeding Nursing Diagnosis #2:
Infection, Risk for, Related to Depressed Body Defenses
Desired Outcome: Client will remain free of infection.
Interventions
Screen all visitors and staff for signs of infection to minimize
Use aseptic technique for all proceduresMonitor temperature to detect possible infection Evaluate client for potential sites of infection: needle punctures, Provide nutritionally complete meals to support the body’s natural Monitor lab values for CBC
Administer G-CSF if prescribed
Measurable Outcomes
Mediport site will remain free of erythema, purulent drainage,
Client will remain afebrile.
Client Teaching
Instruct client and caregivers in correct hand-washing technique
Discharge Planning
Instruct client and caregivers to avoid live attenuated virus
Source: Hacker Handbooks (Boston: Bedford/St. Martin’s, 2011, 2007).
Nursing Diagnosis #3:
Noncompliance, Related to HTN, as Evidenced by Lack of
Consistent Medication Regimen and Adherence to Dietary Plan
Desired Outcome: Client will follow treatment plan.
Interventions
Inquire about reasons for noncompliance
Listen openly and without judgment
Evaluate knowledge of HTN, its long-term effects, and treatment
Arrange for nutritional consult with dietitian
Measurable Outcomes
Client will take medication as prescribed.
Client’s systolic blood pressure will remain in normal range.
Client Teaching
Instruct on medication regimen: appropriate administration and
Provide information on hypertension and its treatment
Discharge Planning
Provide prescriptions
Nursing Diagnosis #4:
Health Maintenance, Ineffective, Related to
Unhealthy Lifestyle and Behaviors
Desired Outcome: Client will make changes in lifestyle.
Interventions
Assist in identifying behaviors that contribute to hypertension
Assist in developing a realistic health maintenance plan including
modifying risk factors such as exercise, diet, and stress Source: Hacker Handbooks (Boston: Bedford/St. Martin’s, 2011, 2007).
Help client and family identify strengths and weaknesses in Measurable Outcomes
Client will verbalize ways to control his hypertension.
Client will identify methods to relieve stress.
Discharge Planning
Provide information on possible exercise programs
Analysis
In the case of E.B., there are two separate disease processes at work—ALL and HTN. The ALL is the most immediately pressing of the two and is indirectly responsible for the client’s current hospitali zation. The chemotherapy treatment for his leukemia has caused thrombocytopenia. This condition places him at high risk for hemorrhage. The anticoagulant therapy for DVT increases this risk even further, not only because it may cause bleeding complications, but because in itself it may cause thrombocytopenia. Therefore, it is imperative to raise his platelet count as quickly as possible. Surprisingly, there were no lab tests ordered to determine his PT and INR, both of which are monitored when a client is on anticoagulant therapy. As his CBC demonstrates, not only is his platelet count low, but his red blood cells are decreased. That is why his physician ordered a transfusion of both PRBCs and platelets. In terms of E.B.’s diagnosis of HTN, he has a positive family history, which is a major risk factor for developing the disease. Excess weight is also a risk factor, and the client has a history Source: Hacker Handbooks (Boston: Bedford/St. Martin’s, 2011, 2007).
of obesity as well. Because exercise is an important factor in managing the excess weight and stress associated with the disease, his leukemia and the chemotherapy treatments aimed at curing E.B.’s leukemia actually negatively affect his ability to manage the hypertension: He is often too weak and fatigued to participate in much physical activity. Additionally, the steroids have resulted in added weight gain, increasing instead of decreasing the problem. To date, the client has failed to maintain a favorable diet regimen. E.B.’s family circumstances must be taken into consideration when managing his treatment. Though he resides with both parents, there is some question as to the support and consistency of care he receives. He often appears very unkempt and is at times noncompliant with his hypertension medication. Due to his parents’ inability to care for a central venous line (CVL) at home, he has a mediport that can be accessed as needed but requires care. On a positive note, the father is aware of their limitations and tries to work with the staff to make sure that E.B.’s ALL is managed appropriately. Source: Hacker Handbooks (Boston: Bedford/St. Martin’s, 2011, 2007).
Hockenberry, M. (2003). Wong’s nursing care of infants and children. St. Louis, MO: Mosby.
LeMone, P., & Burke, K. (2004). Medical-surgical nursing: Critical thinking in client care. Upper Saddle River, NJ: Pearson Education. Source: Hacker Handbooks (Boston: Bedford/St. Martin’s, 2011, 2007).

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