Nursing diagnoses for patients with AML

Five nursing diagnoses for patients with AML:

1. Acute pain related to physical agents (bone marrow packed with leukemic cells) and/or chemical agents (antileukemic treatments) as evidenced by reports of pain

2. Risk for infection related to inadequate secondary defenses, including alterations in mature white blood cells, increased number if immature lymphocytes, and bone marrow suppression

3. Activity intolerance related to generalized weakness; reduced energy stores, or effect of drug therapy as evidenced by external discomfort or dyspnea

4. Risk for bleeding related to reduced platelet counts and suppression of bone marrow

5. Risk for fluid volume deficit related to fluid intake and output or excessive loss (vomiting, bleeding, diarrhea)

Nursing  Diagnosis	Actual or Potential	Related to	Plan and outcome	Nursing intervention
Risk for fluid volume deficit	Potential	Excessive loss and decrease in fluid intake	- Adequate fluid volume for body weight - Mucosa moist - Vital signs stable - UOP 30 ml/hr - Cap refill <2 seconds	- Monitor intake and output, body weight, vital signs. - Evaluation of skin turgor, cap refill and mucous membrane conditions

http://nurseslabs.com/5-leukemia-nursing-care-plans/

http://nursing-care-plan.blogspot.com/2011/12/2-nanda-nursing-diagnosis-and.html

Nursing care for AML patients

Nursing care:	Rationale:	Outcome:
Monitor vital signs	To collect baseline	Nurse will have the resources to identify changes from baseline, and monitor for signs and symptoms of infection
Inspect skin and mucous membranes for petechiae, bleeding gums, frank or occult blood in stool or urine.  Monitor for bruising.	Suppression of bone marrow and platelet production puts patient at risk for bleeding.	Nurse will be able to notice signs and symptoms of bleeding early on in order to manage early intervention
Implement measures to prevent tissue injury or bleeding	Patients with leukemia have fragile tissues and altered clotting mechanisms, which can increase risk of hemorrhage	Nurse will avoid sharp objects, minimize invasive procedures, etc. in order to minimize risk of bleeding or tissue injury
Monitor mucous membranes and signs and symptoms of mucositis.	When receiving chemotherapy, patients who are immunocompromised are at risk for mucositis as they are often affected by severe tissue disruption and pain.	Nurse will be able to notice signs and symptoms of mucositis in order to manage pain early on and implement measures to help with pain.
Provide thorough skin care by keeping patient’s skin and perineal area clean; apply mild lotion or creams to keep the skin from drying or cracking. Thoroughly clean skin before all invasive procedures.	Immunocompromised patients are at a high risk of infection.	By keeping skin from being dry and cracking, this protects their first line of defense against pathogens. These are more measures to eliminate opportunities for infection.
Encourage increased intake of foods high in protein and fluids with adequate fiber.	Promotes healing and dehydration. Constipation can potentiate retention of toxins and risk of rectal irritation or tissue injury.	Patient remains properly hydrated and able to maintain regular bowel function.
Monitor for pain and nausea, and treat accordingly	Nausea is a common side effect of treatment, and pain is common with cancer.	Patient should remain as comfortable as possible, and minimize effects of nausea and pain.

http://www.scribd.com/doc/62062942/Nursing-Care-Plan-AML#scribd

http://nurseslabs.com/5-leukemia-nursing-care-plans/

Treatment and progression of AML

Like many kinds of cancers, the prognosis and treatment options for acute myeloid leukemia depend on many different factors. Including the AML subtype, treatment response, and risk stratification. There are also different factors like your white blood cell count, your age, and your overall health that will have an impact on which treatment option may be the right one for you.

Since there are so many different combinations of contributing factors to one specific patient, we will discuss the two main types of treatment for AML: Chemotherapy, and Bone Marrow Transplants.

Chemotherapy

There are a number of chemotherapy regimens that have shown to be effective against AML. The goal of chemotherapy treatment is to kill the malignant cells without damaging the residual bone marrow cells. 

Clinical studies are constantly underway to discover the best regimens, doses, and treatment schedules for AML.

Bone Marrow Transplants

There are three different kinds of bone marrow transplants:

Allogeneic bone marrow transplants use stem cells from a donor, and are the most common type of transplants used for this disease. Most of the time, the donor’s genes must match some of your own, and be a good “match” for you. This kind of donor can be related, by blood, or unrelated, from a stranger whose genes match yours enough to be fit for a transplant.

            

Umbilical cord blood transplant is a type of allogeneic transplant, where cells are removed from a newborn baby’s umbilical cord, and are then frozen and stored for a recipient who needs it.

Autologous bone marrow transplants use stem cells that were removed from your own body, before receiving high-dose chemotherapy or radiation treatment. Your own stem cells are stored in a freezer and kept aside, this is called cryopreservation.

http://www.seattlecca.org/diseases/adult-acute-myeloid-leukemia-treatment.cfm

http://www.nlm.nih.gov/medlineplus/ency/article/003009.htm

Identifying the Signs and Symptoms of AML

AML, like many different kinds of cancers, can cause many different signs and symptoms. Many of these symptoms may be subtle, or delayed.

It is common for people with AML to feel a general loss of well-being, due to the underproduction of normal bone marrow cells. These kind of symptoms may be to tire easily, or be short of breath after performing normal physical activities.

Symptoms of leukemia are generally non-specific, and include the following:

• Weight loss
• Fatigue
• Fever
• Night sweats
• Loss of appetite
• Paleness
• Signs of bleeding causes by a low platelet count, including:
• Black and blue marks or bruising occurring for no reason or because of a minor injury
• The appearance of pinhead-sized red spots on your skin, called “petechiae”
• Prolonged bleeding from minus cuts or scrapes

Unexplained bruising

Paleness of skin

Petechiae

There are also symptoms caused by high numbers of leukemia cells, which may happen in AML:

• Headache
• Weakness in one side of the body
• Slurred speech
• Confusion
• Sleepiness

If the cancer has spread to other parts of the body, symptoms of AML may include:

• Headaches
• Weakness
• Seizures
• Vomiting
• Trouble with balance
• Facial numbness
• Blurred vision

https://www.lls.org/content/nationalcontent/resourcecenter/freeeducationmaterials/leukemia/pdf/aml.pdf

http://www.cancer.org/cancer/leukemia-acutemyeloidaml/detailedguide/leukemia--acute-myeloid--myelogenous--signs-symptoms

Diagnosing AML and disease progression

According to the American Cancer Society, there is a specific list of recommended screening tests for certain kinds of cancers, but as of yet, there are no special tests recommended to find acute myeloid leukemia early – instead, they recommend that the best way to receive an early diagnosis or find leukemia early is to report any possible symptoms of leukemia to your doctor right away.

Symptoms of leukemia are generally non-specific, and include the following:

• Weight loss
• Fatigue
• Fever
• Night sweats
• Loss of appetite

More information about detailed symptoms will be discussed in a future blog.

If AML is suspected, your doctor will do a series of tests after a thorough collection of your medical history and physical assessment. 

Blood samples are generally taken from a vein in the arm. Since AML is caused by problems with abnormal blood cells, your doctor will need a sample to confirm a trends in an AML diagnosis. With a blood sample, they can run a Complete Blood Count and Peripheral Blood Smear to analyze the different kinds of blood cells and the maturity of various white blood cells.

Bone marrow samples are obtained either by obtaining a bone marrow aspiration or a bone marrow biopsy. These are generally taken from from the back of the pelvic hip bone, but can be taken from other sites as well. In an aspiration, you will lie on your side or belly and receive a local anesthetic by an injection, and after you are numbed, the provider will insert a hollow needle into your bone to withdraw liquid bone marrow. A bone marrow biopsy is done after an 
aspiration, and is done with a slightly larger needle than the one used for aspiration. This removes a small piece of bone for further inspection. The bone marrow tests are used to help diagnose leukemia.


Cytogenetics look at cell's chromosomes under a microscope. Normally, human cells have 23 sets of chromosome that are all generally a certain expected shape and size. Sometimes in AML, the chromosomes of cells have changes that are identifiable under the microscope.






Cytochemistry tests stain cells with chemical dyes that specifically react to certain kinds of leukemia cells. The different colors of the stains help the provider determine what types of cancer cells may be present, for example, AML cells will present differently from ALL cells.





Imaging tests that can help diagnose AML include x-rays, Computed Tomography (CT) scans, and magnetic resonance imaging scans (MRI's). These all create pictures from inside the body. Leukemia doesn't often form tumors, so imaging tests aren't always the most helpful. But when imaging tests are done in people with AML, it is most often to identify infections or other problems from the disease, and not specifically leukemia itself.

Etiology and pathophysiology of AML

Etiology and risk factors of AML

Like many kinds of cancers, the etiology for most cases of AML is unclear, and currently there is no known major cause of AML. However, there are multiple risk factors that are associated with AML. Generally, known risk factors account for only a small number of observed cases. These risk factors are explained and listed below.

Smoking is the only proven lifestyle-related risk factor for AML. It is known that smoking is linked to multiple types of cancer, specifically lung, mouth, throat and larynx cancers, but few people realize that smoking affects cells that don’t come into direct contact with tobacco. The tobacco that is absorbed by the lungs can spread into the bloodstream to many parts and cells of the body.

Genetic disorders and constitutional genetic defects are important risk factors associated with AML. For example, children with Down syndrome have a 10-fold to 20-fold increased likelihood of developing acute leukemia.

Certain chemical exposures increases the risk of developing AML. Long-term exposure to high levels of benzene, a solvent used in oil and gasoline-related industries, rubber industries, and chemical plants.

Certain chemotherapy drugs can also increase the risk of developing AML. Many patients are diagnosed with secondary AML, which is often developed after receiving chemotherapy for separate cancers different from AML.

Radiation exposure in high doses, such as being exposed to nuclear reactor accidents or atomic bombs increases the risk of developing cancer. Radiation treatment for cancer has also been linked to an increased risk in developing AML.

Certain blood disorders and myelodysplastic syndrome (MDS) are also linked to the development of AML. The blood disorders include chronic myeloproliferative disorders such as polycythemia vera, essential thrombocythemia, and idiopathic myelofibrosis. Sometimes treatment of these disoders include radiation or chemotherapy, which further increases the risk of developing AML. Patients with MDS have low blood cell counts and abnormal cells in the blood and bone marrow, which can evolve overtime into AML.

Family history and having a close relative, such as a parent or sibling with AML increases your risk of developing AML. However, most cases of AML are not thought to have a strong genetic link.

Older age is considered to be more common in diagnoses of AML, although AML can even be diagnosed in childhood.

Male gender has been found to be more of a risk factor than female gender, even though the cause of this is unclear.

Disease progression and morbidity of AML

The word “acute” in acute myeloid leukemia denotes to the disease’s rapid progression. As discussed in the first blog post, myeloid leukemia involved the myeloid cells in white blood cells located in the bone marrow. When these cells are abnormal and fail to develop into proper mature white blood cells, patients’ immune systems are incredibly compromised, and regular colds or preventable illnesses become serious fast. Pneumonias can be fatal in patients with AML.

Sources

1. Deschler, B., & Lubbert, M. (2006, October 1). Acute myeloid leukemia: Epidemiology and etiology. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/cncr.22233/full

2. American Cancer Society. (2014, December 1). What are the risk factors for acute myeloid leukemia?

Epidemiology of AML in the US

Now that we have a foundational understanding of what Acute Myeloid Leukemia is, this week we will analyze the frequency and distribution of AML and learn about the specific populations that the disease effects. Many studies have been done and articles written on AML, but in the last five years, a few resources that had overlapping statistics seemed to be most reliable.

By learning about the epidemiology of the disease, we can educate more people about its prevalence and raise awareness, so that treatment options can be discussed as early as possible. Knowing which populations the disease is most prevalent in can also give certain people a good idea of who to look out for in regards to AML.

What is the distribution in the US?

The American Cancer Society’s estimates for leukemia in the US in 2014 as follows:

• About 52,380 new cases of leukemia (all kinds) and 24,090 deaths from leukemia (all kinds)
• About 18,860 new cases of acute myeloid leukemia. Most in adults

Are certain parts of the population more affected than others?

Acute myeloid leukemia is generally a disease of older people and is uncommon before the age of 45. The average age of a patient with AML is about 67 years. Around 50 children (0-14 years) are diagnosed with AML each year.

AML is slightly more common among men than women, but the average lifetime risk in both sexes is less than ½ of 1%.

An estimated 327,520 people in the US are either living with, or are in remission from, leukemia.

Total estimated number of new acute myeloid leukemia cases in the United States for 2014 is a total of 18,860; 11,530 Male cases and 7,330 Female cases

What is the mortality and morbidity from this disease?

According to the American Cancer Society estimates, the total estimated number of deaths from acute myeloid leukemia is10,460. This is made up by 6,010 Male cases and 4,450 Female cases.

When it comes to AML its mortality outlook, generally the younger you are, the more likely your treatment will go well. Of all adults diagnosed with AML, on average around 25% will live for at least 5 years. More than half of people under 45 years old will live for at least 5 years, while around 12 out of 100 people over the age of 65 years will live for more than 5 years.

There are some prognostic factors for AML listed below that has been shown to be harder to treat:

• You are older (>60 years)
• Your white blood cell count is very high when diagnosed
• Your AML developed because you had treatment for another cancer
• You have particular genetic changes (mutations) in leukemia cells
• It takes more than 2 cycles of chemotherapy to get leukemia under control

Cancer research UK. (n.d.). Statistics and outlook for acute myeloid leukaemia. Retrieved from http://www.cancerresearchuk.org/about-cancer/type/aml/treatment/statistics-and-outlook-for-acute-myeloid-leukaemia

American Cancer Society. (n.d.). What are the key statistics about acute myeloid leukemia? Retrieved from http://www.cancer.org/cancer/leukemia-acutemyeloidaml/detailedguide/leukemia-acute-myeloid-myelogenous-key-statistics

Acute myeloid leukaemia (AML). (n.d.). Retrieved from http://www.leukaemia.org.au/blood-cancers/leukaemias/acute-myeloid-leukaemia-aml