Chapter 30 Management of Patients with Hematologic Neoplasms PDF

**Chapter 30: Management of Patients with Hematologic Neoplasms** **Leukemia:** unregulated proliferation of leukocytes in bone marrow which infiltrate meninges, lymph nodes, gums, & skin **Myeloid stem cells:** responsible for producing non-lymphoid/blood cells like RBC, platelets, and WBC **Lym...

**Chapter 30: Management of Patients with Hematologic Neoplasms** **Leukemia:** unregulated proliferation of leukocytes in bone marrow which infiltrate meninges, lymph nodes, gums, & skin **Myeloid stem cells:** responsible for producing non-lymphoid/blood cells like RBC, platelets, and WBC **Lymphoid stem cells**: responsible for producing lymphocytes, which are essential for the immune system - **Acute Myeloid Leukemia (AML)**, pg 2609 - **AML affects the blood and bone marrow. It is characterized by the rapid proliferation of abnormal myeloid cells, which are a type of WBC that normally help fight infection** - **As these blast cells (immature leukocytes) continue to proliferate, they crowd out the normal bone marrow production leading to anemia, thrombocytopenic and either low or elevated WBC counts** - Patho: Defect in stem cell that differentiate into all myeloid cells: monocytes, granulocytes, erythrocytes, & platelets - Most common is nonlymphocytic leukemia - Prognosis highly variable - **Initially, they present w/ nonspecific complaints that occur abruptly or gradually over time; symptoms from abnormal blood cell counts:** - **S/s: fever \[**isn't always due to infections.**\], weight loss, neutropenia, petechiae, weakness, fatigue, bleeding tendencies, pain from enlarged liver or spleen, hyperplasia/overgrowth of gums, & bone pain; gingival bleeding** - Labs: CBC and bone marrow analysis (which shows an excess number of blast cells) - **Tx: aggressive chemotherapy, supportive therapies, hematopoietic stem cell transplantation (HSCT)** - **Chemo phases \[**to obtain remission, induction & consolidation are done**\]:** - **Induction:** based on demographics & history; usually involves high dose of cytarabine & daunorubicin, idarubicin, or mitoxantrone - Aimed at rapidly killing as many cancer cells as possible but also kills healthy cells requiring hospitalization - **Consolidation:** after achieving remission, this phase aims to eliminate any remaining cancer cells that may not be detectable & reduce chance for recurrence of leukemia - \[NOT IN BOOK, in study lab question\] **Maintenance**: keep the cancer in remission and prevent relapse - \[DON'T IN BOOK\]Salvage: used when the cancer has relapsed or has not responded to initial tx - HSCT done following induction & consolidation therapies; most common us allogeneic stem cell transplant - Supportive care may be the only option, antimicrobial therapy & transfusion, death occurs w/in months - Complications: bleeding and infection, which are the major causes of death in these pts - **Nursing Process for Acute Leukemia** - Assessment: family hx, weight loss, bleeding, loss of appetite - Interventions: Managing infection and bleeding - Managing mucositis: Artificial saliva, mouth moisturizer - Improving nutritional intake. Easing pain. - Labs: cultures as needed before antibiotics - Interventions: Decreasing fatigue and activity intolerance. Maintaining F&E balance - Improving self-care. Managing anxiety and grief. Encourage spiritual well-being - **Chronic Myeloid Leukemia (CML)** pg. 2617 - **Patho: Mutation in myeloid stem cell w/ uncontrolled proliferation of abnormal cells** (Philadelphia chromosome) - CML affects the blood and bone marrow. Marrow expands into cavities of long bones, liver, & spleen causing painful enlargements. CML progresses more slowly than AML and is divided into three stages - Stages: - **Chronic phase:** few s/s & not be affected by disease - **Accelerated phas**e: slow or very rapid; marks evolution into acute phase \[blast crisis\] - s/s: **weight loss,** fatigue, anemia, splenomegaly, or dyspnea; bone pain, fever - **Blast crisis:** most advanced; show s/s of acute myeloid then chronic - s/s: **dyspneic or slightly confused** \[d/t decreased lung & brain perfusion\], **enlarged, tender spleen & liver**; **weight loss,** malaise, anorexia - **Medical management:** - **imatinib mesylate (Gleevec)** blocks signals in leukemic cells that express BCR-ABL protein, chemo & HSCT - Goal is to keep dz in acute remission or keeping pt in chronic phase for as long as possible - Oral tyrosine kinase inhibitors (TKIs): the use of tyrosine kinase inhibitors (TKIs) has significantly improved treatment and long-term survival for patients with CML - **Nursing management**: it is extremely important for the nurse to educate the patient about the medication regimen, how to manage side effects, drug interactions, and safe handling - **Acute Lymphocytic Leukemia (ALL)** - **Uncontrolled proliferation of abnormal immature cells/lymphoblasts from lymphoid stem cells** - Prognosis is good for children; 85% for 3-year event-free survival but drops w/ increased age \< 45% adults - **S/sx: Pain from enlarged liver/spleen, bone, CNS; headache and vomiting (book)** - (Carolyn) anemia, pallor, fatigue, weakness, DOE, pain from enlarged liver/spleen, dizziness, petechiae, ecchymosis, lymphadenopathy, and splenomegaly is rare - Tx: chemotherapy, HSCT, monoclonal antibody therapy, **corticosteroids \[dexamethasone\]** - Nursing manag.: same as AML - **Chronic Lymphocytic Leukemia (CLL) (MC leukemia in adults) "A-accumulation, B-symptoms, C-chronic"** - **"Chronically living w/ BBB"** - **Patho: Accumulation of abnormal B lymphocyte clones in the bone, blood, and lymphoid tissues** - **Slow progression** - **KNOW Chart 30-1 risk factors B Symptoms: These symptoms include the following:** - - - - - Tx varies depending on pt and stage - Early: watch weight Late: **IVIG**, chemo agents, HSCT **Malignant lymphomas:** **Hodgkin's Lymphoma pg. 2656** - Begins in a single node spreading into the lymphatic system; the malignant B-lymphocyte is the **Reed-Sternberg cell \[diagnostic hallmark\]** - Figure 30-9 pg. 2661: staging \[listen to see if she emphasized this\] - Stage 1: localized, single lymph node region - Stage 2: 2 or more lymph node regions on same side of diaphragm - Stage 3: 2 or more lymph node regions above & below diaphragm - Stage 4: widespread dz; multiple organs w/ or w/out lymph node involvement - **Risk factors:** **more common in males, ages 15-34 OR \> 60 yrs old, viral infections (HIV, EBV, HHV8), family hx, cytotoxic chemical exposure (agent orange),** also seen in pts w/ long-term immunosuppressive therapy - **KNOW S/sx: individual nodes are painless and firm but not hard, pruritus, viral infections, B symptoms, fever, sweats, weight loss, jaundice, abdominal pain, bone pain, and anemia** - **Diagnosis: Excisional biopsy of lymph node for Reed-Sternberg cell**, assessment of B s/s, x-ray, CT, PET scan - Labs: CBC, BUN, Cr, LFT, elevated ESR - Treatment: determined by stage, maybe chemo, radiation, or both, stem cells for advanced disease - **Nursing management: encourage patients to reduce factors that increase the risk of developing second cancers, such as use of tobacco and alcohol and exposure to environmental carcinogens and excessive sunlight** **Non-Hodgkin's Lymphoma** - Originates from neoplastic growth of lymphoid tissue largely infiltrated w/ malignant cells; many lymph node sites are infiltrated - **KNOW S/sx: starts out as painless swelling in one or more lymph nodes in the neck, axillary region, or groin but later stage is symptomatic, lymphadenopathy and B symptoms, weight loss, fatigue, weakness, fever** - **Diagnosis: Biopsy including bone marrow** and CT/PET scans - **Nursing management** - It is extremely important for the nurse to know the specific disease type, stage of disease, treatment history, and current treatment plan - **Education**: avoiding or stopping smoking, maintaining a normal body weight, practicing good nutrition habits (i.e., consuming fruits and vegetables), and engaging in a minimum of 150 minutes of exercise per week. **Nursing care for HL & NHL (RT = radiation therapy)** - Pancytopenia w/ radiation therapy and/or chemo. N/V w/ RT and/or chemo. Skin problems w/ RT - Constipation or diarrhea w/ RT adn/or chemo. Impaired liver function w/ mets - Sterility for males. Secondary cancer development **Multiple Myeloma** - **WBC cancer involving plasma cells (which makes antibodies)** - **The total protein level in the blood is often elevated due to the increased production of abnormal proteins (M-proteins) produced by the malignant plasma cells** - This type of cancer affects plasma cells, which are responsible for producing antibodies, leading to the accumulation of abnormal cells in the bone marrow and affecting normal blood cell production - **Risk factors, chart 30-3:** - Age: rarely occurs in those less than 35 years of age; risks increase with increasing age - African Americans have twice the risk of Whites - Exposure to radiation, petroleum products, benzenes, and Agent Orange - Family history, particularly among first-degree relatives (e.g., siblings, parents) - Men have slightly higher risks than women. Overweight or obesity - **Clinical manifestations/dx "CRAB features" "Multiple crabs on mye-loma"** - **HyperCalcemia (\>11.5 mg/dL):** causes Thirst, Constipation, Confusion and can lead to coma - **Renal insufficiency** (creatinine \>2 mg/dL or creatinine clearance of less than 40 mL/min) - **Anemia** (hemoglobin \