Leukemia and Lymphoma Med Surg
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Name the Lymphoid Tissues
- Bone Marrow
- Lymph Nodes
What are Lymphomas?
- Overgrowth of Lymphoid tissues due to cancerous changes
- Two types are hodgkins and non-hodgkins lymphoma
What differentiates Hodgkins from Non-Hodgkins Lymphoma
- Hodgkins nodules are individualized and spread in an organized fashion
- Hodgkin nodules have Reed Steinburg Cells
- Non-Hodgkins spreads rapidly and randomly. No Reed Steinburg cells
What are the S/S of Hodgkin's Lymphoma?
- Enlarged lymph nodes in cervical, mediastinal or supraclavicular areas (palpable, painless, rubbery and freely movable)
- These englarged lymph nodes may become tender with alcohol consumption
- Night Sweats
- Presence of Reed Steinberg cells in nodules
- Nodules spread in a chain of lymph nodes in an organized fashion
- More common in teens and young adults, then in older adults >50y/o
How are Reed Steinburg cells distinguished?
Giant cells with two nuclei upon biopsy
What are the causes of HL?
- Cause is unknown, but it may be viral in origin
- Often occurs regardless of risk factors (epstein bar, HIV, genetics, bone marrow transplantation)
How is HL treated?
- It is one of the most treatable types of cancer
- External radiation for stages I and II
- Combo chemo stages III and IV
What is NHL?
- Non Hodgkin's Lymphoma
- Most commonly, there is an infiltration with malignant B cells of the lymph system
- The cause is unknown, more common in older adults
- May be indolent (slow growing) or aggressive and systemic
- Does not Spread in an organized fashion
- No Reed Steinberg Cells
What are the S/S of NHL?
- May be asymptomatic
- Lympadenopathy (swollen lymph nodes)
What is the treatment for NHL?
- Radiation therapy, chemo or both
- Stem cell transplant may be an option for recurrent NHL
What are Leukemias?
- Replacement of Bone marrow with malignant immature WBCs
- They are named according to the cell they affect and whether they are acute or chronic
- The "blast cells" (immature, abnormal WBCs) grow wildly and replace infection fighting WBCs
- These out-crowd all other cells and cross the blood brain barrier
What are the types of Leukemias?
- Acute Lymphocytic Leukemia (ALL): Effects mostly children
- Chronic Lymphocytic Leukemia (CLL): effects mostly elderly
- Acute Myelogenous Leukemia (AML): normally effect adults
- Chronic Myelogenous Leukemia (CML): Shows philadelphia chromosome abnormalities
What are the causes of Leukemias?
- Exact Cause is unknown
- Exposure to chemicals or radiation
- Alteration in Chromosomes
- Large amounts of antineoplastic drugs (chemo)
What is the "miracle" treatment for AML?
- Gleevac (Imatinib): protein kinase inhibitor that interferes with the growth of cancer cells
- -95% remission!
What are the S/S of Leukemias?
- All related to bleeding, anemia and infections
- Similar to the s/s of anemia
What are some nursing diagnosis' for Leukemia?
- Risk for Infection
- Decreased tissue perfusion due to thrombocytopenia
- Activity Intolerance
- Alteration in Nutrition
- 80% of cases occur in children 2-4 y/o and rarely occurs after age 15
- Good response to chemo and radiation
- Immature lymphoblasts
- If untreated, 4-6 mo to live
- If treated, 80-95% complete remission in children
- Immature myoblasts and WBC counts vary
- Most common in adults from adolescence to 50 y/o
- Client is usually asymptomatic except for fatigue and bleeding
- If untreated, survival is 2-4 months
- If patient <60 y/o, remission is 50-75%
- 20% complete remission after 5 years
- Most common in men 50-70 y/o
- Increasing immature lymphocytes
- Slow growth within lymph nodes, bone marrow, liver and spleen
- If caught early (because it's slow growing), it has a good prognosis
- Common men >45 y/o and elderly
- Associated with radiation and presence of the Philadelphia chromosome (esp for radiation for prostate cancer)
- Increase in number of immature myloblasts
How is Leukemia Diagnosed?
- CBC- elevated lymphocytes
- Bone Marrow Aspiration
- Coagulation studies- thrombocytopenia
- Chromosomal Analysis- philadelphia chromosome
- Monitor Serum electrolytes
What are the nursing responsibilities for radiation?
- MRI and CT done prior to therapy to determine location and size
- Temporary tattoos mark the site of radiation
- Promote exercise to combat fatigue
- Enhance Nutrition
- Promote Sleep habits
- Pain control
What are some side effects of radiation?
- Skin changes
- Firmness of breast
- Decreased weight
- Mucocystosis- breakdown of rapidly growing cells esp in oral and GI tract
- Taste changes
Describe the chemotherapy agent Adriamycin (Doxorubicin)
- Used for soft tissue cancers and leukemia
- Doses are calc'd by height and weight (60-75mg/m2) IV
- May cause pink urine and toxic urine output
- Very strong vessicant drug causing tissue necrosis if infiltration occurs
- Side effects include alopecia, N/V, and bone marrow suppression
- THERE IS A LIFETIME LIMIT ON THIS DRUG not to exceed 550mg/m2
- Steroids may be used in conjunction to mask adverse effects
Name several chemo vesicants
- Etoposide (VePesid)
- Vincristin (Oncovin)
- Vinblastin (Velan)
- Dactinomycin (Cosmegen)
Describe Vincristine (Oncovin)
- Comes from the Rosy periwinkle plant
- Used in many cancers, including leukemia
- Inhibits cells division
- Dose is 1.5-2mg/m2Side Effects include muscle/nerve pain, nausea and vomiting, headache, alopecia, wt loss, dry mouth, dizziness, diarrhea or constipation
- Monitor Liver Enzymes
- Isolation precautions (neutropenic)
What is Tumor Lysis Syndrome?
- This is an emergency!!
- During rapid tumor breakdown, large numbers of cells are killed rapidly, spilling potassium and metabolic bi-products into the blood
- Early recognition is key!! (check for kidney failure)
What are the E/F imbalances in TLS?
- High Uric Acid
What is Epoetin Alfa (Epogen)?
- It is an RBC stimulator. It works by stimulating erythropoietin in the kidneys to produce more RBCs
- Side effects include increased BP, flu-like symptoms and a transient rash/urticaria
- Given subcut (At home) 3x a week or IV
- Roll the vial DO NOT SHAKE
- It takes 2-8 weeks for HCT levels to increase
- Monitor Iron labs, may need suppliments
What is Filgrastim (Neupogen)?
- A WBC stimualtor. It is a granulocyte stimulating factor from human DNA
- It promotes growth of neutrophils and enhances function of mature neutrophils
- Usually given at an office appointment, often after chemo
- 1mcg/kg/day up to 6 consecutive days IV or Subcut
- Side effects include ST depression on ECG, bone pain, thrombocytopenia and drug fever
- It ONLY be diluted in D5W
- It must be refrigerated and DO NOT SHAKE
- Teach infection control
Describe Neutropenic Precautions
- Absolute neutropenia is <1,00 or an ANC of <1
- HANDWASHING is still the most important!
- Often called reverse isolation
- No sick staff, no standing water, no uncooked food or fresh fruits/veg and no flowers
- This has serious psychosocial implications for the patient
- ASSESS for infection without the fever, due to low neutrophil count
What are some side effects of chemo that the nurse needs to teach and care for?
- Hair loss and skin changes
- Reproductive issues
- Bladder and bowel changes
- Gastric Irritation
- Pica (Eating non-food items)
- *Skilled emotional support
Describe the different kinds of bone marrow transplants
- Allogenic Transplant: transplant from a donor, usually a genetic match like a biological sibling
- Autologous Transplant: stem cells removed from patient prior to treatment and replaced after treatment
- Synergetic Transplant: stem cells created in a lab
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