Interventions for Clients with Hematologic Problems WHITE BLOOD CELL DISORDERS.

Interventions for Clients Interventions for Clients with Hematologic with Hematologic

ProblemsProblems

WHITE BLOOD CELL WHITE BLOOD CELL DISORDERSDISORDERS

White blood cells (WBCs), or White blood cells (WBCs), or leukocytes, leukocytes, provide provide protection from invading non-self cells and cancer protection from invading non-self cells and cancer cells in several ways. cells in several ways.

These protective functions depend on These protective functions depend on maintaining normal numbers and ratios of many maintaining normal numbers and ratios of many specific mature, circulating leukocytes. specific mature, circulating leukocytes.

When any one type of WBC is present in either When any one type of WBC is present in either abnormally high or abnormally low amounts, abnormally high or abnormally low amounts, hematopoietic function and immune function may hematopoietic function and immune function may be altered to some degree, placing clients at risk be altered to some degree, placing clients at risk for specific complicationsfor specific complications

Differentiating characteristics of the four types of leukemia

LEUKEMIALEUKEMIA

EtiologyEtiology ionizing radiationionizing radiation chemicals and drugschemicals and drugs marrow marrow hypoplasia hypoplasia (slow functioning with (slow functioning with

less than the normal production rate of less than the normal production rate of blood cells)blood cells)

environmental interactionsenvironmental interactions genetic factorsgenetic factors viral factorsviral factors immunologic factorsimmunologic factors the interaction of these factors the interaction of these factors

LEUKEMIALEUKEMIA

LEUKEMIALEUKEMIALaboratory assessmentLaboratory assessment decreased hemoglobin and hematocrit levelsdecreased hemoglobin and hematocrit levels decreased platelet countdecreased platelet count altered white blood cell (WBC) count. altered white blood cell (WBC) count.

The WBC count may be low, normal, or elevated but usually The WBC count may be low, normal, or elevated but usually is quite elevated; counts of 20,000 to 100,000 are common. is quite elevated; counts of 20,000 to 100,000 are common. The client with a higher WBC count on diagnosis has a The client with a higher WBC count on diagnosis has a poorer prognosispoorer prognosis

The definitive test for leukemia includes various The definitive test for leukemia includes various examinations of cells obtained from bone marrow aspiration examinations of cells obtained from bone marrow aspiration and biopsy. The bone marrow is full of leukemic and biopsy. The bone marrow is full of leukemic blast blast phase cells phase cells (immature cells that are dividing). (immature cells that are dividing).

LEUKEMIALEUKEMIA DRUG THERAPY FOR LEUKEMIADRUG THERAPY FOR LEUKEMIA. Drug therapy for clients with . Drug therapy for clients with

AML is divided into three distinctive phases: in duction, AML is divided into three distinctive phases: in duction, consolidation, and maintenance.consolidation, and maintenance.

Induction therapy. Induction therapy. Induction therapy is intensive and consists of Induction therapy is intensive and consists of combination chemotherapy initiated at the time of diagnosis. This combination chemotherapy initiated at the time of diagnosis. This therapy is aimed at achieving a rapid, complete remission of all therapy is aimed at achieving a rapid, complete remission of all manifestations of disease. A typical course of aggressive manifestations of disease. A typical course of aggressive chemotherapy includes IV administration of cytosine arabinoside chemotherapy includes IV administration of cytosine arabinoside for 7 days with concomitant administration of daunorubicin for the for 7 days with concomitant administration of daunorubicin for the first 3 days.first 3 days.

A major side effect of these agents is severe bone marrow A major side effect of these agents is severe bone marrow suppression. As a result, the client becomes even more vulnerable suppression. As a result, the client becomes even more vulnerable to infection than before the treatment started. Prolonged to infection than before the treatment started. Prolonged hospitalizations are common while the client is immunosuppressed. hospitalizations are common while the client is immunosuppressed.

Recovery of bone marrow function requires at least 2 to 3 weeks, Recovery of bone marrow function requires at least 2 to 3 weeks, during which time the client must be protected from life-during which time the client must be protected from life-threatening infections. threatening infections.

Other adverse reactions include nausea, vomiting, diarrhea, Other adverse reactions include nausea, vomiting, diarrhea, alopecia (hair loss), stomatitis (mouth sores), kidney toxicity, liver alopecia (hair loss), stomatitis (mouth sores), kidney toxicity, liver toxicity, and cardiac toxicity.toxicity, and cardiac toxicity.

LEUKEMIALEUKEMIA Consolidation therapy. Consolidation therapy. Consolidation therapy usually Consolidation therapy usually

consists of another course of either the same agents consists of another course of either the same agents used for induction at a different dosage or a different used for induction at a different dosage or a different combination of chemotherapeutic agents. This combination of chemotherapeutic agents. This treatment occurs early in remission, and its intent is to treatment occurs early in remission, and its intent is to cure. At some institutions, consolidation therapy is a cure. At some institutions, consolidation therapy is a single course of chemotherapy; at others, it involves single course of chemotherapy; at others, it involves regularly scheduled, repeated courses of regularly scheduled, repeated courses of chemotherapy for 1 to 2 years.chemotherapy for 1 to 2 years.

Maintenance therapy. Maintenance therapy. Maintenance therapy may be Maintenance therapy may be prescribed for months to years after successful prescribed for months to years after successful induction and consolidation therapies. It is commonly induction and consolidation therapies. It is commonly indicated for clients with acute lymphocytic leukemia indicated for clients with acute lymphocytic leukemia (ALL). The purpose is to maintain the remission (ALL). The purpose is to maintain the remission achieved through induction and consolidation. achieved through induction and consolidation. Maintenance agents are milder and are often given Maintenance agents are milder and are often given orally for 2 to 5 years.orally for 2 to 5 years.

LEUKEMIALEUKEMIA

DRUG THERAPY FOR INFECTION. DRUG THERAPY FOR INFECTION. Drug Drug therapy is the primary defense against therapy is the primary defense against infections that develop in clients infections that develop in clients undergoing therapy for AML. undergoing therapy for AML.

Agents used depend on the sensitivity of Agents used depend on the sensitivity of the specific organism causing the the specific organism causing the infection, as well as the extent of the infection, as well as the extent of the infection, and are categorized by infection, and are categorized by specificity as antibacterial, antiviral, or specificity as antibacterial, antiviral, or antifungal. antifungal.

LEUKEMIALEUKEMIA

INFECTION PROTECTIONINFECTION PROTECTION SKIN CARESKIN CARE RESPIRATORY CARERESPIRATORY CARE BONE MARROW BONE MARROW

TRANSPLANTATIONTRANSPLANTATION

LEUKEMIALEUKEMIA Sources of stem cells.Sources of stem cells. BMT originated with the use of BMT originated with the use of allogeneic allogeneic

bone marrow transplantation bone marrow transplantation (transplantation of identical bone (transplantation of identical bone marrow from a sibling) and has advanced to the use of human marrow from a sibling) and has advanced to the use of human leukocyte antigen (HLA)-matched stem cells from the umbilical cords leukocyte antigen (HLA)-matched stem cells from the umbilical cords of unrelated donors.of unrelated donors.

Transplants can be classified based on the source of stem cells. Transplants can be classified based on the source of stem cells. In In autologous transplants, autologous transplants, the clients receive their own stem cells, the clients receive their own stem cells,

which were collected before therapy. which were collected before therapy. Syngeneic transplants Syngeneic transplants are rare and involve the client's own are rare and involve the client's own

identical twin as the donor of stem cells. identical twin as the donor of stem cells. In In allogeneic transplants, allogeneic transplants, a closely HLA-matched sibling or an a closely HLA-matched sibling or an

unrelated donor provides the stem cells. Stem cells for unrelated donor provides the stem cells. Stem cells for transplantation may be obtained by one of the following methods: transplantation may be obtained by one of the following methods: bone marrow harvest, peripheral stem cell pheresis, or umbilical cord bone marrow harvest, peripheral stem cell pheresis, or umbilical cord blood stem cellblood stem cell

Transplantation procedures have five phases: stem cell procurement, Transplantation procedures have five phases: stem cell procurement, conditioning regimen, transplantation, engraftment, and conditioning regimen, transplantation, engraftment, and posttransplantation recoveryposttransplantation recovery

Timing and steps of allogenic bone marrow transplantation

LEUKEMIALEUKEMIAHEALTH TEACHINGHEALTH TEACHING The client and the family The client and the family

need to be educated about need to be educated about the importance of continuing the importance of continuing therapy and appropriate therapy and appropriate medical follow-up, despite medical follow-up, despite the unpleasant side effects the unpleasant side effects of therapy. of therapy.

Many clients go home with a Many clients go home with a central venous catheter in central venous catheter in place and require place and require instructions about its care instructions about its care and maintenance. These and maintenance. These guidelines may be altered guidelines may be altered depending on the home depending on the home setting, assistance available, setting, assistance available, and agency policyand agency policy

LEUKEMIALEUKEMIA Protecting the client from infection after Protecting the client from infection after

discharge from the hospital is just as important as discharge from the hospital is just as important as it was during hospitalization. it was during hospitalization.

The nurse urges the client to use proper hygiene The nurse urges the client to use proper hygiene and to avoid crowds or others with infections. and to avoid crowds or others with infections. Neither the client nor any household member Neither the client nor any household member should receive live virus immunization should receive live virus immunization (poliomyelitis, measles, or rubella) for 2 years (poliomyelitis, measles, or rubella) for 2 years after transplantation. after transplantation.

The client should continue mouth care regimens The client should continue mouth care regimens at home. at home.

The nurse emphasizes that the client should The nurse emphasizes that the client should immediately notify the physician if he or she immediately notify the physician if he or she experiences fever or any other sign of infection. experiences fever or any other sign of infection.

LEUKEMIALEUKEMIA Because platelet recovery is usually slower than recovery of Because platelet recovery is usually slower than recovery of

white blood cells (WBCs), many clients return home still at white blood cells (WBCs), many clients return home still at risk for bleeding. risk for bleeding.

Thrombocytopenia may be present for 6 months following Thrombocytopenia may be present for 6 months following transplantation. transplantation.

The nurse reinforces the safety and bleeding precautions The nurse reinforces the safety and bleeding precautions initiated in the hospital, emphasizing that the client must initiated in the hospital, emphasizing that the client must follow these precautions until the platelet count is above follow these precautions until the platelet count is above 50,000. 50,000.

The client and family are instructed to assess for petechiae, The client and family are instructed to assess for petechiae, avoid trauma and sharp objects, apply pressure to wounds avoid trauma and sharp objects, apply pressure to wounds for 10 minutes, and report any unusual symptoms, for 10 minutes, and report any unusual symptoms, including blood in the stool or urine, or headache that does including blood in the stool or urine, or headache that does not respond to acetaminophen. not respond to acetaminophen.

MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA Malignant lymphomas occur as a result of abnormal Malignant lymphomas occur as a result of abnormal

overgrowth of one type of leukocyte (lymphocytes); they overgrowth of one type of leukocyte (lymphocytes); they differ from the leukemias in the degree of maturation of the differ from the leukemias in the degree of maturation of the affected cells and the location of cell production. affected cells and the location of cell production.

Lymphomas are malignancies characterized by a Lymphomas are malignancies characterized by a proliferation of committed lymphocytes rather than stem proliferation of committed lymphocytes rather than stem cell precursors (as in leukemia). cell precursors (as in leukemia).

This proliferation occurs not in bone marrow but in other This proliferation occurs not in bone marrow but in other lymphoid tissues scattered throughout the body, especially lymphoid tissues scattered throughout the body, especially the lymph nodes and spleen. the lymph nodes and spleen.

Lymphomas are actually solid tumors rather than cellular Lymphomas are actually solid tumors rather than cellular suspensions within the blood andsuspensions within the blood and bone marrow, and they bone marrow, and they fall into two major categories among adults: Hodgkin's fall into two major categories among adults: Hodgkin's lymphoma and non-Hodgkin's lymphomalymphoma and non-Hodgkin's lymphoma

Hodgkin's LymphomaHodgkin's Lymphoma Hodgkin's lymphoma is a cancer that can affect any age group, Hodgkin's lymphoma is a cancer that can affect any age group,

although incidence peaks first in people in their mid-to-late 20s and although incidence peaks first in people in their mid-to-late 20s and then in people older than 50 years of age. then in people older than 50 years of age.

Men and women are affected equally in the first group, but the disease Men and women are affected equally in the first group, but the disease is more prevalent in men in the older group.is more prevalent in men in the older group.

Factors implicated as possible causes of Hodgkin's lymphoma include Factors implicated as possible causes of Hodgkin's lymphoma include viral infections and previous exposure to alkylating chemical agents. viral infections and previous exposure to alkylating chemical agents.

This cancer usually originates in a single lymph node or a single chain This cancer usually originates in a single lymph node or a single chain of nodes. The lymphoid tissues within the node undergo malignant of nodes. The lymphoid tissues within the node undergo malignant transformation, usually initiating some inflammatory processes. These transformation, usually initiating some inflammatory processes. These nodes contain a specific transformed cell type, the nodes contain a specific transformed cell type, the Reed-Sternberg Reed-Sternberg cell, cell, a marker for Hodgkin's lymphoma. a marker for Hodgkin's lymphoma.

The disease first The disease first metastasizes metastasizes (spreads) to other nearby lymphoid (spreads) to other nearby lymphoid structures and eventually invades nonlymphoid tissuesstructures and eventually invades nonlymphoid tissues

Hodgkin's LymphomaHodgkin's LymphomaAssessmentAssessment Assessment most often reveals a greatly enlarged but painless Assessment most often reveals a greatly enlarged but painless

lymph node or nodes, usually the earliest manifestation of Hodgkin's lymph node or nodes, usually the earliest manifestation of Hodgkin's lymphoma. The client also often experiences fever, malaise, and lymphoma. The client also often experiences fever, malaise, and night sweats. More specific clinical manifestations depend on the site night sweats. More specific clinical manifestations depend on the site (or sites) of malignancy and the extent of disease.(or sites) of malignancy and the extent of disease.

Diagnosis and grade are established when biopsy of a node or mass Diagnosis and grade are established when biopsy of a node or mass reveals Reed-Sternberg cells. reveals Reed-Sternberg cells.

The client then undergoes extensive staging procedures to The client then undergoes extensive staging procedures to determine the exact extent of disease. Staging must be detailed and determine the exact extent of disease. Staging must be detailed and accurate because the treatment regimen is determined by the accurate because the treatment regimen is determined by the extent of disease. extent of disease.

Staging procedures for Hodgkin's lymphoma include biopsies of Staging procedures for Hodgkin's lymphoma include biopsies of distant lymph nodes, computed tomography (CT) of the thorax and distant lymph nodes, computed tomography (CT) of the thorax and abdomen, staging laparotomy, a complete blood count (CBC), liver abdomen, staging laparotomy, a complete blood count (CBC), liver function studies, and bilateral bone marrow biopsiesfunction studies, and bilateral bone marrow biopsies

Manifestations and staging criteria for Hodgkin's lymphoma

Hodgkin's LymphomaHodgkin's Lymphoma

InterventionsInterventions Hodgkin's lymphoma is now one of the most Hodgkin's lymphoma is now one of the most

curable types of cancer. curable types of cancer.

Generally, for stage I and stage II disease without Generally, for stage I and stage II disease without mediastinal node involvement, the treatment of mediastinal node involvement, the treatment of choice is extensive external radiation of involved choice is extensive external radiation of involved lymph node regions. lymph node regions.

With more extensive disease, radiation coupled With more extensive disease, radiation coupled with an aggressive multiagent chemotherapy with an aggressive multiagent chemotherapy regimen is most effective in achieving a cureregimen is most effective in achieving a cure

Non-Hodgkin's Non-Hodgkin's LymphomaLymphoma

Non-Hodgkin's lymphoma is the classification for all cancers originating Non-Hodgkin's lymphoma is the classification for all cancers originating from lymphoid tissues that are not diagnosed as Hodgkin's lymphoma. from lymphoid tissues that are not diagnosed as Hodgkin's lymphoma.

There are more than 12 subtypes of non-Hodgkin's lymphoma, including There are more than 12 subtypes of non-Hodgkin's lymphoma, including low-grade, intermediate, and high-grade lymphomas.low-grade, intermediate, and high-grade lymphomas.

The low-grade lymphomas usually arise from B-cell lymphocytes and The low-grade lymphomas usually arise from B-cell lymphocytes and progress slowly. Although clients with low-grade lymphomas have longer progress slowly. Although clients with low-grade lymphomas have longer survival rates, the diseases are less responsive to treatment and, survival rates, the diseases are less responsive to treatment and, consequently, cures are rare.consequently, cures are rare.

At the other end of the spectrum are the high-grade lymphomas, which are At the other end of the spectrum are the high-grade lymphomas, which are aggressive tumors of usually mixed cellularity with rapid doubling times. aggressive tumors of usually mixed cellularity with rapid doubling times. High-grade lymphomas are more responsive to chemotherapy, and the High-grade lymphomas are more responsive to chemotherapy, and the chances for a longterm cure are greater.chances for a longterm cure are greater.

Most non-Hodgkin's lymphomas arise from lymph nodes, but they can Most non-Hodgkin's lymphomas arise from lymph nodes, but they can originate in virtually any tissue or organ. A low-grade lymphoma also can originate in virtually any tissue or organ. A low-grade lymphoma also can convert to a higher-grade lymphoma. Definitive causes are unknown, but convert to a higher-grade lymphoma. Definitive causes are unknown, but viral infection, exposure to ionizing radiation, autoimmune disorders, and viral infection, exposure to ionizing radiation, autoimmune disorders, and exposure to toxic chemicals have all been implicatedexposure to toxic chemicals have all been implicated

Non-Hodgkin's Non-Hodgkin's LymphomaLymphoma

Because lymphomas may arise from lymphoid cells in any Because lymphomas may arise from lymphoid cells in any tissue and because the malignancy can spread to any organ, tissue and because the malignancy can spread to any organ, assessment reveals no specific clinical manifestations other assessment reveals no specific clinical manifestations other than lymphadenopathy common to all types of lymphoma. than lymphadenopathy common to all types of lymphoma.

Diagnosis is made from the histologic features apparent on Diagnosis is made from the histologic features apparent on biopsy of any suspicious node or mass. biopsy of any suspicious node or mass.

Classification of the specific lymphoma subtype is based on a Classification of the specific lymphoma subtype is based on a complex grading of surface markers, cytogenetic features, complex grading of surface markers, cytogenetic features, cell size, and expression of viral antigens. Staging is similar cell size, and expression of viral antigens. Staging is similar to that for Hodgkin's lymphoma.to that for Hodgkin's lymphoma.

Treatment consists of radiation therapy and multiagent Treatment consists of radiation therapy and multiagent chemotherapy. Nursing care needs are similar to those for chemotherapy. Nursing care needs are similar to those for clients with Hodgkin's lymphoma, with additional organ-clients with Hodgkin's lymphoma, with additional organ-specific problems taken into account if the disease is widely specific problems taken into account if the disease is widely disseminateddisseminated