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Chapter 33 Management of Clients with Leukemia and Lymphoma
Cancers of the Hematopoietic System <ul><li>Result from proliferation of malignant cells originating in: </li></ul><ul><ul...
Hematopoietic Cell Disorders: Leukemia: Etiology & Risk Factors <ul><ul><li>Leukemia: malignant disease of blood-forming o...
Hematopoietic Cell Disorders: Leukemia: Pathophysiology <ul><li>Classified according to: </li></ul><ul><li>Cell line invol...
Hematopoietic Cell Disorders: Leukemia <ul><li>Acute leukemia:  </li></ul><ul><ul><li>acute lymphocytic leukemia (ALL)  </...
Hematopoietic Cell Disorders: Acute Leukemia <ul><li>Acute myeloid leukemia (AML) </li></ul><ul><li>Defect in hematopoieti...
 
AML:  Complications <ul><li>Major causes of death: </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><ul><li>Risk inc...
Treatment of AML <ul><li>Goal is remission </li></ul><ul><li>Induction Therapy:  Aggressive chemo </li></ul><ul><ul><li>Re...
Tumor Lysis Syndrome  <ul><li>Due to massive leukemic cell destruction & release of intracellular electrolytes & fluids in...
Tumor Lysis Syndrome --- Tx <ul><li>Increased fluids </li></ul><ul><li>Alkalinization of urine (sodium bicarb) </li></ul><...
Tx of AML---cont’d. <ul><li>Supportive care </li></ul><ul><ul><li>Blood products (PRBCs & platelets) </li></ul></ul><ul><u...
Alternative Treatments <ul><li>BMT (Bone Marrow Transplant) </li></ul><ul><li>PBSCT  (Peripheral Blood Stem Cell transplan...
Post-remission Therapy <ul><li>Consolidation therapy </li></ul><ul><ul><li>To eliminate any residual leukemia cells </li><...
Chronic Myelogenous Leukemia (CML) <ul><li>Malignancy of myeloid stem cells---increased blast cells </li></ul><ul><li>Bone...
CML:  Clinical Manifestations <ul><li>Sx variable;  some are asymptomatic </li></ul><ul><li>Very high leukocyte counts may...
Treatment of CML —chronic stage <ul><li>Oral administration of Gleevec (tyrosine kinase inhibitor) </li></ul><ul><li>Oral ...
CML----Transformation Stage <ul><li>This stage marks the progress toward acute form (blast crisis) </li></ul><ul><li>May h...
CML---blast crisis <ul><li>Tx similar to induction therapy for acute leukemias </li></ul><ul><ul><li>Lymphoid blast crisis...
Treatment-- CML <ul><li>Potential cure with bone marrow transplant or PBSCT </li></ul><ul><ul><li>Greater chance of cure i...
Acute Lymphocytic Leukemia (ALL) <ul><li>Uncontrolled malignant proliferation of lymphoblasts (esp. B-cell precursor) </li...
ALL <ul><li>Immature lymphocytes crowd development of normal cells; inhibiting hematopoiesis  </li></ul><ul><li>Leukocyte ...
Treatment of ALL <ul><li>Goal is complete remission </li></ul><ul><li>Corticosteroids </li></ul><ul><li>Vinca alkaloids </...
Chronic Lymphocytic Leukemia (CLL) <ul><li>2/3 are older than 60 </li></ul><ul><li>Most common type of leukemia in US & Eu...
CLL--pathophysiology <ul><li>Most cells are mature but escape apoptosis, resulting in excessive accumulation of cells in b...
CLL---S&S <ul><li>Many are asymptomatic </li></ul><ul><li>Increased lymphocyte count </li></ul><ul><li>Lymphadenopathy </l...
CLL--Treatment <ul><li>No tx required in early stages </li></ul><ul><li>Later stages or symptomatic: </li></ul><ul><ul><li...
Diagnostic Findings <ul><li>Bone marrow aspiration—increase marrow & immature </li></ul><ul><li>Lumbar puncture—blast cell...
Acute & Chronic Leukemia: Nursing Diagnoses <ul><li>Ineffective Protection; Risk for Infection r 2   neutropenia, chemothe...
Acute & Chronic Leukemia: Nursing Diagnoses--cont’d <ul><li>Fatigue & Activity Intolerance  r 2  anemia </li></ul><ul><li>...
Nursing Considerations <ul><li>Mucositis:  oral + rectal areas </li></ul><ul><ul><li>Oral assessment & hygiene with soft t...
Nursing Considerations <ul><li>Nutritional Intake </li></ul><ul><ul><li>Mouth care before & after meals </li></ul></ul><ul...
Nursing Considerations <ul><li>Pain & comfort </li></ul><ul><ul><li>Tylenol to reduce fever </li></ul></ul><ul><ul><li>Spo...
Nursing Considerations <ul><li>Fatigue </li></ul><ul><ul><li>Balance activities & rest </li></ul></ul><ul><ul><li>Sit in c...
Nursing Considerations <ul><li>Anxiety </li></ul><ul><ul><li>Emotional support/ providing information </li></ul></ul><ul><...
Nursing Considerations:  Bleeding Precautions <ul><li>Assess skin, GI, GU, neuro status, VS, heart & lungs every shift </l...
Nursing Considerations:  Neutropenic Precautions <ul><li>Assess signs of infection every shift:  skin, mouth, lungs, GI, G...
Nursing Considerations:  Neutropenic Precautions <ul><li>No one with URI or sore throat should visit or care for patient <...
Nursing Considerations:  Neutropenic Precautions <ul><li>Eliminate fresh fruits & veg. or salads </li></ul><ul><li>No supp...
Nursing Considerations:  Neutropenic Precautions <ul><li>Oral hygiene after meals & every 4 hrs </li></ul><ul><li>Do not u...
Lymphomas  <ul><ul><li>General term for group of cancers originating in lymphatic system </li></ul></ul><ul><ul><li>Result...
Lymphomas  -- 2 categories <ul><li>Hodgkin’s Disease—specialized form; initiates in a single node & spreads along lymph sy...
S&S of Hodgkin’s Lymphoma <ul><ul><li>Painless enlargement of one or more lymph nodes on one side of the neck </li></ul></...
Hodgkin’s Lymphoma <ul><li>Diagnostic Findings </li></ul><ul><ul><li>Lymph node biopsy: distinct, large cell—Reed-Sternber...
Treatment of Hodgkin’s <ul><li>Goal is cure </li></ul><ul><li>Tx based on stage of disease </li></ul><ul><li>2-4 months of...
Survival Rates <ul><li>Hodgkin’s lymphoma one of most curable forms of cancer </li></ul><ul><li>Many cured after 1 treatme...
NHL—Clinical  Manifestations <ul><ul><li>Generalized or localized lymphadenopathy; most common in cervical, axillary, ingu...
NHL: Medical Management <ul><li>Tx based on classification & stage of disease </li></ul><ul><li>Early stage, localized NHL...
Survival Rate <ul><li>5-year survival rate increased from 31% in whites (1960-1963) to 63.8% for all races </li></ul><ul><...
Multiple Myeloma <ul><li>Malignant disease of plasma cells (most mature form of B-lymphocyte) which produce increased amou...
Multiple Myeloma---S&S <ul><li>Bone pain in back or ribs which increases during the day </li></ul><ul><li>Lytic lesions se...
Multiple Myeloma---Diagnosis <ul><li>Bence-Jones protein on serum protein electrophoresis, or in urine </li></ul><ul><li>L...
Multiple Myeloma----Tx <ul><li>No cure, even with BMT or PBSCT </li></ul><ul><li>Chemo is primary treatment </li></ul><ul>...
Nursing care for Multiple Myeloma <ul><li>Pain control:  NSAIDs or opioids, body mechanics, braces </li></ul><ul><li>Teach...
Bone Marrow Transplantation <ul><li>Indications—aplastic anemia, malignant disorders, non-malignant  hematologic disorders...
Bone Marrow Transplantation: Types <ul><li>Allogeneic </li></ul><ul><li>from relative or unrelated donor with close HLA ma...
Bone Marrow Transplantation: Types <ul><li>Syngeneic </li></ul><ul><li>Donated by identical twin </li></ul><ul><li>Perfect...
Bone Marrow Transplantation: Types <ul><li>Autologous </li></ul><ul><li>Used for pts without donors or those who require a...
Allogeneic Transplant <ul><li>Donor preparation—extensive work-up </li></ul><ul><ul><li>Collection: informed consent </li>...
<ul><li>Graft-versus-host disease: most common & potentially disastrous complication of allogeneic BMT & may occur 7 to 30...
GVHD <ul><li>Donor’s immune cells (T cells) attack body of “host” </li></ul><ul><li>Reduce by  </li></ul><ul><ul><li>Close...
Post-BMT care <ul><li>1 st  100 days after BMT are crucial:  immune system & hematopoiesis recovering </li></ul><ul><li>Hi...
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Nrsg 200 leukemia

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  • Hematopoietic stem cell differentiates into all myeloid cells: monocytes, granulocytes (neutrophils, basophils, eosinophils), erythrocytes, and platelets.
  • Acute Myelogenous (AML) or Acute Nonlymphocytic (ANLL) leukemia affects the hematopoietic stem cell that differentiates into all myeloid cells -monocytes -granulocytes: basophils, neutrophils, eosinophils, erthrocytes, &amp; platelets
  • ITP= idiopathic thromobocytopenic purpura
  • See Chart 33-9 on page 1076
  • See Chart 33-8 on pages 1069-70
  • Transcript of "Nrsg 200 leukemia"

    1. 1. Chapter 33 Management of Clients with Leukemia and Lymphoma
    2. 2. Cancers of the Hematopoietic System <ul><li>Result from proliferation of malignant cells originating in: </li></ul><ul><ul><li>Bone marrow </li></ul></ul><ul><ul><li>Thymus </li></ul></ul><ul><ul><li>Lymphatic tissue </li></ul></ul>
    3. 3. Hematopoietic Cell Disorders: Leukemia: Etiology & Risk Factors <ul><ul><li>Leukemia: malignant disease of blood-forming organs (bone marrow) </li></ul></ul><ul><ul><li>Common feature: unregulated proliferation or accumulation of WBCs in bone marrow, replacing normal marrow elements </li></ul></ul><ul><ul><li>Proliferation in liver, spleen, & lymph nodes & invasion of nonhematologic organs </li></ul></ul><ul><ul><li>Cause is unknown; some evidence of genetic influence, viral pathogenesis, or radiation/chemical exposure </li></ul></ul><ul><ul><ul><li>Alkylating agents </li></ul></ul></ul>
    4. 4. Hematopoietic Cell Disorders: Leukemia: Pathophysiology <ul><li>Classified according to: </li></ul><ul><li>Cell line involved </li></ul><ul><ul><li>Lymphoid </li></ul></ul><ul><ul><li>Myeloid </li></ul></ul><ul><li>Maturity of malignant cells </li></ul><ul><ul><li>Acute (undifferentiated cells) </li></ul></ul><ul><ul><ul><li>Onset of sx is abrupt; progresses rapidly </li></ul></ul></ul><ul><ul><li>Chronic (mature cells) </li></ul></ul><ul><ul><ul><li>Sx evolve over months to years </li></ul></ul></ul>
    5. 5. Hematopoietic Cell Disorders: Leukemia <ul><li>Acute leukemia: </li></ul><ul><ul><li>acute lymphocytic leukemia (ALL) </li></ul></ul><ul><ul><li>acute myeloid leukemia (AML) </li></ul></ul><ul><li>Chronic leukemia: </li></ul><ul><ul><li>chronic myeloid leukemia (CML) </li></ul></ul><ul><ul><li>chronic lymphocytic leukemia (CLL) </li></ul></ul>
    6. 6. Hematopoietic Cell Disorders: Acute Leukemia <ul><li>Acute myeloid leukemia (AML) </li></ul><ul><li>Defect in hematopoietic stem cell </li></ul><ul><li>Affects all ages; increases with age </li></ul><ul><li>S/S: insufficient normal blood cells: </li></ul><ul><ul><li>Infection (neutropenia) </li></ul></ul><ul><ul><li>Weakness/fatigue (anemia) </li></ul></ul><ul><ul><li>Bleeding (thromobocytopenia) </li></ul></ul><ul><li>Prognosis: </li></ul><ul><ul><li>Older pts have worse prognosis </li></ul></ul><ul><ul><li>Secondary form R/T alkylating agents have poorer prognosis </li></ul></ul>
    7. 8. AML: Complications <ul><li>Major causes of death: </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><ul><li>Risk increases with severity of neutropenia </li></ul></ul></ul><ul><ul><ul><ul><li>Risk of fungal infection increases </li></ul></ul></ul></ul><ul><ul><li>Bleeding </li></ul></ul><ul><ul><ul><li>Major bleeding can occur with platelets less than 10,000 </li></ul></ul></ul><ul><ul><ul><li>Common sites are GI, pulmonary, intracranial </li></ul></ul></ul>
    8. 9. Treatment of AML <ul><li>Goal is remission </li></ul><ul><li>Induction Therapy: Aggressive chemo </li></ul><ul><ul><li>Requires several weeks hospitalization </li></ul></ul><ul><ul><li>Aim is to eradicate leukemic cells but also eradicates normal cells </li></ul></ul><ul><ul><li>Patient severely neutropenic, anemic & thrombocytopenic---very ill! </li></ul></ul><ul><ul><li>Mucositis causes diarrhea, inability to eat </li></ul></ul><ul><ul><li>Cytosar, Ara-C, Cerubidine, Novantrone </li></ul></ul>
    9. 10. Tumor Lysis Syndrome <ul><li>Due to massive leukemic cell destruction & release of intracellular electrolytes & fluids into systemic circ. </li></ul><ul><li>Increased uric acid & phosphorus </li></ul><ul><ul><li>Increased risk of renal stones/ ARF </li></ul></ul><ul><li>Increased potassium/ low Ca++ </li></ul><ul><ul><li>Cardiac dysrhythmias </li></ul></ul><ul><ul><li>Muscle cramps, weakness, tetany, confusion, seizures </li></ul></ul>
    10. 11. Tumor Lysis Syndrome --- Tx <ul><li>Increased fluids </li></ul><ul><li>Alkalinization of urine (sodium bicarb) </li></ul><ul><li>Allopurinol to prevent crystallization of uric acid </li></ul>
    11. 12. Tx of AML---cont’d. <ul><li>Supportive care </li></ul><ul><ul><li>Blood products (PRBCs & platelets) </li></ul></ul><ul><ul><li>Treat infections </li></ul></ul><ul><li>Neupogen or Leukine can shorten period of neutropenia </li></ul>
    12. 13. Alternative Treatments <ul><li>BMT (Bone Marrow Transplant) </li></ul><ul><li>PBSCT (Peripheral Blood Stem Cell transplant) </li></ul><ul><ul><li>Aggressive chemo (& radiation) to destroy patient’s bone marrow followed by infusion of donor stem cells </li></ul></ul><ul><ul><li>At risk for graft-versus-host reaction </li></ul></ul>
    13. 14. Post-remission Therapy <ul><li>Consolidation therapy </li></ul><ul><ul><li>To eliminate any residual leukemia cells </li></ul></ul><ul><ul><li>Multiple treatment cycles, often with same agents used for induction but at lower doses </li></ul></ul>
    14. 15. Chronic Myelogenous Leukemia (CML) <ul><li>Malignancy of myeloid stem cells---increased blast cells </li></ul><ul><li>Bone marrow expands into cavities of long bones & cells formed in liver & spleen </li></ul><ul><ul><li>Enlarged, tender spleen & liver </li></ul></ul><ul><li>Milder than acute with more normal cells present </li></ul><ul><li>90-95% genetic abnormality—”Philadelphia chromosome” 22 translocated onto chromosome 9 </li></ul><ul><li>Uncommon under 20 yrs of age </li></ul>
    15. 16. CML: Clinical Manifestations <ul><li>Sx variable; some are asymptomatic </li></ul><ul><li>Very high leukocyte counts may lead to SOB, mild confusion </li></ul><ul><li>Enlarged, tender spleen </li></ul><ul><li>Malaise, anorexia, weight loss </li></ul><ul><li>3 stages: </li></ul><ul><ul><li>Chronic </li></ul></ul><ul><ul><li>Transformation </li></ul></ul><ul><ul><li>Blast crisis: Sx worsen as disease progresses </li></ul></ul>
    16. 17. Treatment of CML —chronic stage <ul><li>Oral administration of Gleevec (tyrosine kinase inhibitor) </li></ul><ul><li>Oral chemo agents Hydrea, Myleran </li></ul><ul><li>Leukapheresis: Leukocytes removed from patient’s blood, then returned </li></ul><ul><li>Interferon-alfa, cytosine </li></ul><ul><ul><li>Given SQ daily </li></ul></ul><ul><ul><li>Fatigue, depression, anorexia, mucositis, inability to concentrate </li></ul></ul>
    17. 18. CML----Transformation Stage <ul><li>This stage marks the progress toward acute form (blast crisis) </li></ul><ul><li>May have bone pain, fevers </li></ul><ul><li>Enlarged spleen </li></ul><ul><li>Worsening anemia, thrombocyopenia </li></ul>
    18. 19. CML---blast crisis <ul><li>Tx similar to induction therapy for acute leukemias </li></ul><ul><ul><li>Lymphoid blast crisis more likely to re-enter chronic phase </li></ul></ul><ul><li>Life-threatening infections & bleeding occur frequently </li></ul>
    19. 20. Treatment-- CML <ul><li>Potential cure with bone marrow transplant or PBSCT </li></ul><ul><ul><li>Greater chance of cure if done during chronic phase </li></ul></ul><ul><ul><li>Considered for pts younger than 65 </li></ul></ul><ul><li>Imatinib (Gleevec) therapy can decrease need for transplant </li></ul>
    20. 21. Acute Lymphocytic Leukemia (ALL) <ul><li>Uncontrolled malignant proliferation of lymphoblasts (esp. B-cell precursor) </li></ul><ul><li>20% of blast cells have chromosome translocation similar to CML </li></ul><ul><li>Most common in young children </li></ul><ul><ul><li>Males > females </li></ul></ul><ul><ul><li>Peak at 4 yrs </li></ul></ul><ul><ul><li>Uncommon after age 15 </li></ul></ul>
    21. 22. ALL <ul><li>Immature lymphocytes crowd development of normal cells; inhibiting hematopoiesis </li></ul><ul><li>Leukocyte counts may be high or low but always high % of immature cells </li></ul><ul><li>Infiltrate liver, spleen, CNS (leading to H/A & vomiting) </li></ul><ul><li>Bone pain </li></ul><ul><li>80% survive 5 yrs </li></ul>
    22. 23. Treatment of ALL <ul><li>Goal is complete remission </li></ul><ul><li>Corticosteroids </li></ul><ul><li>Vinca alkaloids </li></ul><ul><li>May include cranial irradiation or intrathecal MTX for CNS involvement </li></ul><ul><li>Imatinib used for those with chromosome abnormality </li></ul><ul><li>Monoclonal antibodies being studied </li></ul><ul><li>BMT or PBSCT may be done if illness recurs </li></ul>
    23. 24. Chronic Lymphocytic Leukemia (CLL) <ul><li>2/3 are older than 60 </li></ul><ul><li>Most common type of leukemia in US & Europe—rare in Asia </li></ul><ul><li>Occurs more often in males </li></ul>
    24. 25. CLL--pathophysiology <ul><li>Most cells are mature but escape apoptosis, resulting in excessive accumulation of cells in bone marrow & circulation </li></ul><ul><li>Elevated lymphocyte count in early stages, more than 100,000 </li></ul><ul><li>Lymphocytes trapped in lymph nodes: Enlarged painful nodes with enlarged liver & spleen </li></ul><ul><li>Anemia & thrombocytopenia occur in later stages </li></ul><ul><li>Autoimmune complications: hemolytic anemia or ITP (idiopathic thrombocytopenic purpura) </li></ul>
    25. 26. CLL---S&S <ul><li>Many are asymptomatic </li></ul><ul><li>Increased lymphocyte count </li></ul><ul><li>Lymphadenopathy </li></ul><ul><li>Splenomegaly, hepatomegaly </li></ul><ul><li>“ B” symptoms </li></ul><ul><ul><li>Fever, night sweats, weight loss </li></ul></ul><ul><ul><li>Defects in humoral & cellular immunity </li></ul></ul><ul><ul><ul><li>Anergy with skin testing </li></ul></ul></ul><ul><ul><ul><li>Infections are common </li></ul></ul></ul>
    26. 27. CLL--Treatment <ul><li>No tx required in early stages </li></ul><ul><li>Later stages or symptomatic: </li></ul><ul><ul><li>Monoclonal antibodies being used more (Rituxan, Campath) </li></ul></ul><ul><ul><ul><li>At risk for infection: Septra + antivirals used x 2 months after tx ends </li></ul></ul></ul><ul><ul><li>Fludara, steroids or Leukeran </li></ul></ul><ul><ul><ul><li>S/E Leukeran: bone marrow suppression with risk of opportunistic infections </li></ul></ul></ul>
    27. 28. Diagnostic Findings <ul><li>Bone marrow aspiration—increase marrow & immature </li></ul><ul><li>Lumbar puncture—blast cells in CSF </li></ul><ul><li>Chest x-ray, MRI, CT—to detect lesions & sites of infection </li></ul><ul><li>CBC count varies greatly; WBC may be very hi or very low </li></ul><ul><ul><li>Anemia </li></ul></ul><ul><ul><li>Thrombocytopenia </li></ul></ul><ul><ul><li>Leukopenia </li></ul></ul><ul><li>Lymphangiography, Lymph node biopsy—locate malignant lesions & classify </li></ul>
    28. 29. Acute & Chronic Leukemia: Nursing Diagnoses <ul><li>Ineffective Protection; Risk for Infection r 2 neutropenia, chemotherapy, radiation therapy </li></ul><ul><li>Ineffective Protection; Risk for Hemorrhage r 2 thrombocytopenia 2 2 treatment </li></ul><ul><li>Imbalanced Nutrition: Less Than Body Requirements r 2 lack of appetite, nausea & vomiting; gi proliferative changes, chemo </li></ul><ul><li>Deficient Fluid Volume r 2 decrease in intake; cancer process; chemotherapy </li></ul>
    29. 30. Acute & Chronic Leukemia: Nursing Diagnoses--cont’d <ul><li>Fatigue & Activity Intolerance r 2 anemia </li></ul><ul><li>Disturbed Body Image; Sexual Dysfunction r 2 change in appearance, in function, and roles </li></ul><ul><li>Ineffective Therapeutic Regimen Management r 2 length, complexity, expense of Tx </li></ul><ul><li>Impaired Skin Integrity r 2 toxic effects of chemotherapy </li></ul>
    30. 31. Nursing Considerations <ul><li>Mucositis: oral + rectal areas </li></ul><ul><ul><li>Oral assessment & hygiene with soft toothbrushes or swabs </li></ul></ul><ul><ul><li>Rinses with NS or baking soda </li></ul></ul><ul><ul><li>Tx of yeast in mouth (Mycelex, Diflucan) </li></ul></ul><ul><ul><li>Cleanse & dry peri area thoroughly </li></ul></ul>
    31. 32. Nursing Considerations <ul><li>Nutritional Intake </li></ul><ul><ul><li>Mouth care before & after meals </li></ul></ul><ul><ul><li>Analgesics before eating </li></ul></ul><ul><ul><li>Anti-emetics </li></ul></ul><ul><ul><li>Small frequent meals of soft foods at moderate temperature </li></ul></ul><ul><ul><li>Avoid uncooked fruits & vegs </li></ul></ul><ul><ul><li>Nutritional supplements </li></ul></ul><ul><ul><li>Daily weights/ I&O </li></ul></ul><ul><ul><li>May require parenteral nutrition </li></ul></ul>
    32. 33. Nursing Considerations <ul><li>Pain & comfort </li></ul><ul><ul><li>Tylenol to reduce fever </li></ul></ul><ul><ul><li>Sponging with cool water for fever (avoid cold water or ice packs) </li></ul></ul><ul><ul><li>Back & shoulder massage to ease muscle aches </li></ul></ul><ul><ul><li>PCA </li></ul></ul><ul><ul><li>Interrupted sleep </li></ul></ul>
    33. 34. Nursing Considerations <ul><li>Fatigue </li></ul><ul><ul><li>Balance activities & rest </li></ul></ul><ul><ul><li>Sit in chair rather than lying in bed </li></ul></ul><ul><ul><li>HEPA filter mask may allow neutropenic patient to walk hallways </li></ul></ul><ul><ul><li>Consider PT/ stationary bikes </li></ul></ul><ul><ul><li>Encourage self-care </li></ul></ul>
    34. 35. Nursing Considerations <ul><li>Anxiety </li></ul><ul><ul><li>Emotional support/ providing information </li></ul></ul><ul><ul><li>Depression/ grief common </li></ul></ul><ul><ul><li>Support spiritual well-being </li></ul></ul>
    35. 36. Nursing Considerations: Bleeding Precautions <ul><li>Assess skin, GI, GU, neuro status, VS, heart & lungs every shift </li></ul><ul><ul><li>Test urine, emesis & stools for occult blood </li></ul></ul><ul><li>Monitor CBC/ platelets </li></ul><ul><li>Avoid ASA </li></ul><ul><li>No IM injections, rectal temps or supp. </li></ul><ul><li>Use stool softeners </li></ul><ul><li>Hold venipuncture sites x 5 minutes </li></ul><ul><li>No flossing of teeth/ use soft toothbrush </li></ul><ul><li>Avoid suctioning </li></ul><ul><li>Electric razor </li></ul><ul><li>Avoid vigorous nose blowing </li></ul><ul><li>Pad side rails, prevent falls </li></ul>
    36. 37. Nursing Considerations: Neutropenic Precautions <ul><li>Assess signs of infection every shift: skin, mouth, lungs, GI, GU, neuro, VS including temp </li></ul><ul><li>Monitor CBC. Call MD for neutrophil count less than 1000 </li></ul><ul><li>Monitor CXR, C&S reports </li></ul>
    37. 38. Nursing Considerations: Neutropenic Precautions <ul><li>No one with URI or sore throat should visit or care for patient </li></ul><ul><li>Care for neutropenic pt. first if possible </li></ul><ul><li>Needs private room if ANC less than 1000 </li></ul><ul><li>No fresh flowers </li></ul><ul><li>Room cleaned daily </li></ul><ul><li>Change water in containers every 24 hours (e.g. O2 humidification bottles) </li></ul>
    38. 39. Nursing Considerations: Neutropenic Precautions <ul><li>Eliminate fresh fruits & veg. or salads </li></ul><ul><li>No suppositories, rectal temps or enema </li></ul><ul><li>Deep breathing every 4 hours while awake </li></ul><ul><li>Ambulate: HEPA mask in halls </li></ul><ul><li>Prevent skin dryness </li></ul><ul><li>Meticulous hygiene including peri care </li></ul>
    39. 40. Nursing Considerations: Neutropenic Precautions <ul><li>Oral hygiene after meals & every 4 hrs </li></ul><ul><li>Do not use plastic IV catheters if ANC is less than 500; central line preferred </li></ul><ul><li>Inspect IV site every shift; use aseptic technique for dressing changes </li></ul><ul><li>Give antimicrobials on time </li></ul>
    40. 41. Lymphomas <ul><ul><li>General term for group of cancers originating in lymphatic system </li></ul></ul><ul><ul><li>Results when lymphocyte (WBC) undergoes malignant change & multiplies, crowding out healthy cells & creating tumors which enlarge lymph nodes or other sites </li></ul></ul><ul><ul><li>Tumors of primary lymphoid tissue (thymus & bone marrow) </li></ul></ul><ul><ul><li>Secondary lymphoid tissue (lymph nodes, spleen, tonsils, & intestinal lymphoid tissue) </li></ul></ul>
    41. 42. Lymphomas -- 2 categories <ul><li>Hodgkin’s Disease—specialized form; initiates in a single node & spreads along lymph system </li></ul><ul><ul><li>Viral etiology suspected (EBV) </li></ul></ul><ul><li>Non-Hodgkin’s (NHL’s)—heterogeneous groups of cancers that originate from neoplastic growth of lymphoid tissue </li></ul><ul><ul><li>Most involve B-lymphocytes </li></ul></ul><ul><ul><li>Spread is unpredictable </li></ul></ul><ul><ul><li>Now 6 th most common type of cancer in US </li></ul></ul><ul><ul><li>Incidence increased in immunodeficiencies, prior CA tx </li></ul></ul>
    42. 43. S&S of Hodgkin’s Lymphoma <ul><ul><li>Painless enlargement of one or more lymph nodes on one side of the neck </li></ul></ul><ul><ul><li>Mediastinal mass on CXR </li></ul></ul><ul><ul><li>Pruritus (cause unknown) </li></ul></ul><ul><ul><li>All organs are vulnerable to invasion </li></ul></ul><ul><ul><ul><li>Cough, jaundice, abdominal or bone pain </li></ul></ul></ul><ul><ul><ul><li>“ B” symptoms: fever, sweats, weight loss </li></ul></ul></ul><ul><ul><li>Mild anemia, platelets usually WNL </li></ul></ul><ul><ul><li>Leukocyte count high or low </li></ul></ul><ul><ul><li>Elevated sed rate </li></ul></ul><ul><ul><li>Impaired cellular immunity (skin tests) </li></ul></ul><ul><ul><li>Herpes zoster infections are common </li></ul></ul>
    43. 44. Hodgkin’s Lymphoma <ul><li>Diagnostic Findings </li></ul><ul><ul><li>Lymph node biopsy: distinct, large cell—Reed-Sternberg cells </li></ul></ul><ul><ul><li>Bone marrow biopsy </li></ul></ul><ul><ul><li>Chest x-ray </li></ul></ul><ul><ul><li>CT/ PET scan </li></ul></ul><ul><ul><li>Bone scan </li></ul></ul>
    44. 45. Treatment of Hodgkin’s <ul><li>Goal is cure </li></ul><ul><li>Tx based on stage of disease </li></ul><ul><li>2-4 months of chemo followed by radiation (early stages may receive radiation alone) </li></ul><ul><ul><li>Adriamycin, bleomycin, vinblastine & dacarbazine (“ABVD” therapy) </li></ul></ul><ul><li>Recurrent disease treated with high-dose chemo then BMT </li></ul>
    45. 46. Survival Rates <ul><li>Hodgkin’s lymphoma one of most curable forms of cancer </li></ul><ul><li>Many cured after 1 treatment </li></ul><ul><li>5-yr survival 86% all races </li></ul><ul><li>5-yr survival 95.2% for 0-14 yr </li></ul><ul><li>Can develop other cancers (lung, breast)---encourage healthy lifestyle to avoid risks </li></ul>
    46. 47. NHL—Clinical Manifestations <ul><ul><li>Generalized or localized lymphadenopathy; most common in cervical, axillary, inguinal, femoral </li></ul></ul><ul><ul><li>Painless </li></ul></ul><ul><ul><li>May wax & wane in less aggressive types </li></ul></ul><ul><ul><li>S/S diffuse NHL variable & more systemic </li></ul></ul><ul><ul><li>Night sweats, fever, wt loss (“B” symptoms) </li></ul></ul><ul><ul><li>Hepato-or-splenomegaly </li></ul></ul><ul><ul><li>Lymphomatous masses can compromise organ function </li></ul></ul>
    47. 48. NHL: Medical Management <ul><li>Tx based on classification & stage of disease </li></ul><ul><li>Early stage, localized NHL sometimes treated with radiation </li></ul><ul><li>Widespread disease requires chemotherapy or combined treatment </li></ul><ul><li>Tx after relapse is controversial: BMT or PBSCT may be done if less than 60 years old </li></ul>
    48. 49. Survival Rate <ul><li>5-year survival rate increased from 31% in whites (1960-1963) to 63.8% for all races </li></ul><ul><li>5-year survival rate for children, 0-19, 83.5% </li></ul><ul><li>Est. 19,730 deaths from lymphoma in 2007 (18,660 NHL/1070 HL) </li></ul>
    49. 50. Multiple Myeloma <ul><li>Malignant disease of plasma cells (most mature form of B-lymphocyte) which produce increased amount of non-functional immunoglobulin (M-protein) </li></ul><ul><li>Total protein levels are elevated </li></ul><ul><li>Abnormal plasma cells also secrete substance to stimulate angiogenesis </li></ul>
    50. 51. Multiple Myeloma---S&S <ul><li>Bone pain in back or ribs which increases during the day </li></ul><ul><li>Lytic lesions seen on x-ray; may develop spinal fractures </li></ul><ul><li>Hypercalcemia: thirst, constipation, confusion </li></ul><ul><li>Renal failure due to proteins damaging renal tubules </li></ul><ul><li>Anemia: Fatigue, weakness </li></ul><ul><li>Serum hyperviscosity with bleeding from nose or mouth, or heart failure </li></ul>
    51. 52. Multiple Myeloma---Diagnosis <ul><li>Bence-Jones protein on serum protein electrophoresis, or in urine </li></ul><ul><li>Lytic bone lesions on x-ray </li></ul><ul><li>Bone marrow biopsy confirms dx: presence of sheets of plasma cells </li></ul>
    52. 53. Multiple Myeloma----Tx <ul><li>No cure, even with BMT or PBSCT </li></ul><ul><li>Chemo is primary treatment </li></ul><ul><ul><li>Steroids, Alkeran, Cytoxan, Adriamycin </li></ul></ul><ul><li>Radiation may strengthen bone at a specific lesion if at risk for fx or spinal compression </li></ul><ul><li>Bisphosphonates, vertebroplasty for compression fx </li></ul><ul><li>Plasmapheresis for hyperviscosity </li></ul><ul><li>Thalidomide inhibits angiogenesis </li></ul>
    53. 54. Nursing care for Multiple Myeloma <ul><li>Pain control: NSAIDs or opioids, body mechanics, braces </li></ul><ul><li>Teach about S&S hypercalcemia </li></ul><ul><ul><li>Hydration important </li></ul></ul><ul><li>Monitor renal function; dialysis may be necessary </li></ul><ul><li>Bacterial infections common due to impaired antibody production </li></ul><ul><ul><li>Needs flu & Pneumovax vaccines </li></ul></ul><ul><ul><li>Watch & report signs of infection </li></ul></ul>
    54. 55. Bone Marrow Transplantation <ul><li>Indications—aplastic anemia, malignant disorders, non-malignant hematologic disorders, immunodeficiency disorders </li></ul><ul><li>Bone marrow types </li></ul><ul><ul><li>Allogeneic (donor other than patient) </li></ul></ul><ul><ul><li>Syngeneic (from identical twin) </li></ul></ul><ul><ul><li>Autologous (from patient) </li></ul></ul><ul><li>Histocompatability testing for allogeneic & syngeneic transplants </li></ul>
    55. 56. Bone Marrow Transplantation: Types <ul><li>Allogeneic </li></ul><ul><li>from relative or unrelated donor with close HLA match </li></ul><ul><li>Previously most common </li></ul><ul><li>BUT highest rate m/m due to complications of incompatibility </li></ul><ul><li>Increased use of autologous & peripheral stem cell transplants </li></ul>
    56. 57. Bone Marrow Transplantation: Types <ul><li>Syngeneic </li></ul><ul><li>Donated by identical twin </li></ul><ul><li>Perfect HLA match </li></ul><ul><li>Eliminates rejection risk </li></ul><ul><li>Higher rate of leukemic relapse (GVHD has anti-leukemic effect) </li></ul>
    57. 58. Bone Marrow Transplantation: Types <ul><li>Autologous </li></ul><ul><li>Used for pts without donors or those who require ablative doses of chemo for an aggressive malignancy </li></ul><ul><li>Eliminates risk of immunologic response </li></ul><ul><li>Relapse is frequent </li></ul><ul><ul><li>Contamination of bm by malignant cells? </li></ul></ul><ul><ul><li>Failure of pre-transplant chemo? </li></ul></ul>
    58. 59. Allogeneic Transplant <ul><li>Donor preparation—extensive work-up </li></ul><ul><ul><li>Collection: informed consent </li></ul></ul><ul><ul><ul><li>Marrow collection </li></ul></ul></ul><ul><ul><ul><li>Peripheral stem cell collection </li></ul></ul></ul><ul><li>Recipient preparation (“conditioning regimen”) </li></ul><ul><ul><li>Malignant cells destroyed </li></ul></ul><ul><ul><li>Marrow cavities emptied </li></ul></ul><ul><ul><li>Bone marrow infused </li></ul></ul>
    59. 60. <ul><li>Graft-versus-host disease: most common & potentially disastrous complication of allogeneic BMT & may occur 7 to 30 days after infusion </li></ul><ul><ul><li>Acute: staged R/T organ system affected </li></ul></ul><ul><ul><ul><li>Skin, liver, GI, pulmonary, encephalopathy </li></ul></ul></ul><ul><ul><li>Chronic: occurs ~ 100 days post-transplant; resembles autoimmune collagen-vascular disorders (SLE; scleroderma; Sjogren’s); severe case is often fatal </li></ul></ul>GVHD
    60. 61. GVHD <ul><li>Donor’s immune cells (T cells) attack body of “host” </li></ul><ul><li>Reduce by </li></ul><ul><ul><li>Close match of donor </li></ul></ul><ul><ul><li>Drugs to prevent (cyclosporine & methotrexate) </li></ul></ul><ul><ul><li>Removing T cells from donated cells </li></ul></ul><ul><li>Early Tx = better outcomes </li></ul>
    61. 62. Post-BMT care <ul><li>1 st 100 days after BMT are crucial: immune system & hematopoiesis recovering </li></ul><ul><li>High risk of death from infection or bleeding </li></ul><ul><li>Also at risk for venous occlusive disease after high-dose chemo </li></ul><ul><li>At risk for tumor lysis syndrome & acute tubular necrosis </li></ul><ul><li>Total body irradiation often leads to sterility, cataracts </li></ul>
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