Blood Cancers and Neutropenia

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Term used to denote a decrease in all components of a WBC, including granulocytes, monocytes and lymphocytes...

Leukopenia

Term to denote a deficiency in neutrophils, eosinophils, neutrophils, and basophils...

Granulocytopenia

Which components of white blood cells counts are closely monitored as a good indicator of a patient's risk for infection?

Neutrophilic granulocytes

__________ is the term for a reduction in neutrophils.

Neutropenia

What is considered severe neutropenia?

A count less than 500 per microliter

What is the normal range for neutrophils per microliter?

4000-11,000

What are the three components for determining the clinical significance of neutropenia?

-the rapidity of the decline, - the degree of neutropenia -the duration

What factors, coupled with neutropenia, caused an increased risk of a serious infection?

Being older than 60, having an existing infection, having diabetes, being in the hospital

What is the most common cause of a neutropenia?

Iatrogenic effects from medications used to treat other conditions like cancer or autoimmune conditions

What causes the clinical manifestations of infection to be missed in patients with neutropenia?

Typically, the normal s/s aren't present due to a reduced phagocytic response. So, the normal redness, swelling, warmth, fever, pus formation, etc. is absent.

What are the signs and symptoms that require an immediate response if a patient has neutropenia?

Any fever, sore throat, dysphagia, ulcerative lesions on the cheeks or throat, diarrhea, rectal tenderness or rectal/vaginal itching, vaginal discharge, SOA or a non-productive cough.

What organisms are commonly responsible for systemic infections in patients with neutropenia?

They are usually normal flora like Staphylococcus aureus, candida or aspergillus. Reactivation of herpes zoster or herpes simplex are also common.

What are the primary diagnostic studies for neutropenia?

WBC and a bone marrow aspiration/biopsy

What are the major nursing responsibilities related to neutropenia?

Strict handwashing, visitor restriction, private room, monitor for s/s of an infection (temp 100.4 and up), collection of cultures if warranted, administration of antibiotics.

A patient with neutropenia has a developed a fever and you have taken serial blood cultures and sputum samples. The lab says it will take about 2 hours to process the gram stains to guide therapies. What is your priority at this point?

Administer antibiotics. They have to be given within an hour of the onset of fever. Broad spectrum antibiotics via IV are usually ordered.

Cephalosporins are common medications given to patients with neutropenia that have developed a fever. What are the common side effects of this type of drug?

Rashes, fever, pruritis

Aminoglycosides are commonly prescribed to patients who have neutropenia that have developed a fever. What are two common side effects that a nurse should monitor for?

Ototoxicity and nephrotoxicity

What type of organism is typically the cause of an infection in a patient with neutropenia of a long duration?

Fungal, the longer the neutropenia, the greater the risk of a fungal infection

Neupogen/filgrastim and Neulasta/pegfilgrastim are G-CSF medications that are commonly given to patients with neutropenia to stimulate the production and function of _________.

Neutrophils

Leukine or Prokine (sargramostim)are GM-CSF medications that are given to patients with neutropenia to stimulate the production of _________.

Monocytes and Neutrophils

What is the most important factor for reducing infections in a neutropenic patient?

Handwashing by any and all persons who come into contact with the patient.

What are some neutropenic guidelines that are commonly employed for a patient with prolonged neutropenia, like a patient who has had a bone marrow transplant?

-Avoiding tap water, fresh fruit, fresh vegetables -prophylactic antibiotics and antifungals.

What are some teaching points for a patient with neutropenia to manage their care from home?

-Wash hands! -Notify the doctor if they develop a fever, chills, or feel hot, develop redness, swelling, discharge, new pain, changes in bowel habits, cough, sore throat or blisters -avoid crowds, avoid raw foods like shushi or Caesar salads, blue cheese, fruits that cannot be peeled, vegetables that cannot be well cleaned -Shower/bathe daily -No gardening or cleaning up after pets when they poop or have accidents

You have an elderly patient with neutropenia. They have suddenly become confused and are exhibiting signs of delirium. What illness should you suspect?

Pneumonia. Elderly individuals often develop delirium instead of a cough due to age related changes.

T/F Patients with neutropenia should not have fresh flowers or plants in their room.

True. They can introduce pathogens to the patient.

__________ is a group of related hematologic disorders characterized by a change in the quantity and quality of bone marrow elements. Peripheral blood cytopenias and hypercellular bone marrow exhibiting dysplastic changes are hallmark findings.

Myelodysplastic Syndrome (MDS)

What age group is most likely to be diagnosed with myelodysplastic syndrome?

People aged 60 and up

Why is myelodysplastic syndrome called a clonal disorder?

Some bone marrow stem cells continue to function normally while others, called a specific clone, do not

How is myelodysplastic syndrome (MDS) different from acute myelogenous anemia (AML)?

AML dysplastic cells show little maturation whereas MDS cells always display some degree of maturity.

What is the clinical picture of a patient with myelodysplastic syndrome?

MDS is usually diagnosed when trying to determine the cause symptoms caused by neutropenia, anemia or thrombocytopenia (fatigue, easy bruising, sensitivity to cold, etc.).

How is MDS (myelodysplastic syndrome) diagnosed?

Through a bone marrow aspiration and biopsy, accompanied with laboratory studies

What is the first effective treatment for people with MDS?

Azacitidine (Vidaza), a drug that helps restore normal growth control and differentiation of hematopoietic cells.

High dose chemotherapy and allogeneic HSCT (hematopoietic stem cell transplantation) have been used to treat bone marrow dysfunction associated with MDS but it is a very aggressive treatment. For that reason, it is only recommended if the patient is aged...

55-60 years old

________ is the general term used to describe a group of malignant disorders affecting the blood and blood-forming tissues of the bone marrow, lymph system and spleen.

Leukemia

Are children or adults more likely to develop leukemia?

Adults, they are ten times more likely to have it

There are many potential causes of leukemia. Name the general possibilities...

genetics, chemical insults, radiation, viruses, and immunologic deficiencies.

What careers or exposures have been identified with an increased risk of developing leukemias?

There has been an increased incidence identified in radiologists, persons who have lived nuclear bomb test sites, near nuclear reactor accidents, survivors of Hiroshima and Nagasaki bombings, in persons previously treated with chemo or radiation.

________ leukemia has been identified as a type caused by a virus. It is most prevalent in Japan, parts of the Caribbean and central Africa.

Adult T-cell

________ leukemias are characterized by clonal proliferation of immature hematopoietic cells, followed by cellular replication and expansion of that malignant clone.

Acute

_______ leukemias involve more mature forms of WBCs and disease onset is gradual.

Chronic

This type of leukemia is the most common acute form in adults (85%)...

Acute Myelogenous Leukemia (AML)

_________ leukemia usually has an abrupt, dramatic onset appearing as a serious infection or abnormal bleeding. It is caused by an abnormal proliferation of myeloblasts which leads to hyperplasia of bone marrow and the spleen.

AML (Acute Myelogenous Leukemia)

Which type of leukemia is a child most likely to be diagnosed with?

Acute Lymphoytic Anemia (ALL)

Who has a better survival rate of ALL (Acute Lymphocytic Leukemia)? Children or Adults?

Children have an 80% survival rate, adults have a 40%

Which type of leukemia often is often accompanied by a leukemic meningitis?

ALL (Acute Lymphocytic Leukemia)

Which leukemia would present with the following? Bone, joint, abdominal pain. Transverse rarefaction of the epiphyses of the long bones on Xray. Increased intracranial pressure, vomiting, hepatosplenomegaly, lymphadenopathy, lethargy.

Acute Lymphocytic Leukemia (ALL)

What signs and symptoms would you expect to see in a patient in the early stages of Chronic Myelogenous Leukemia (CML)?

None, there are usually no symptoms early in the disease (maybe an increased platelet count)

Which form of leukemia is often identified by the presence of Philadelphia chromosomes?

CML-chronic myelogenous leukemia

Which type of leukemia has two phases, the chronic-stable phase and the blastic phase?

CML Chronic Myelogenous Leukemia

What is the prognosis of a patient in the blastic phase of CML?

Not good, they usually die within a few months

Which type of leukemia presents with the following clinical picture? Increased sweating, splenomegaly with sternal tenderness, high platelet count early in the disease, increase in polymorphonuclear neutrophils, normal lymphocytes and monocytes, Philadelphia chromosome

CML-Chronic Myelogenous Leukemia

Which leukemia? Caused by prodution and accumulation of funtionally inactive but long-lived, mature-appearing lymphocytes

Chronic Lymphocytic Leukemia (CLL)

Which leukemia? Caused by uncontrolled proliferation of myeloblasts

Acute Myelogenous Leukemia (AML)

Which leukemia? Caused by proliferation of immature lymphocytes in the bone marrow

Acute Lymphoytic Leukemia (ALL)

Which leukemia? Caused by excessive mature neoplastic granulocytes in the bone marrow

Chronic Myelogenous Leukemia (CML)

What is the most common leukemia in adults?

Chronic Lymphocytic Leukemia (note: Acute Myelogenous Leukemia is the most common ACUTE leukemia in adults)

The major symptoms of this leukemia are called by lymphadenopathy. Enlarged lymph nodes compress nerves causing pain or paralysis, mediastinal lymph node enlargement can cause pulmonary symptoms...

CLL-Chronic Lymphocytic Leukemia

What are the characteristics of a patient commonly diagnosed with hairy cell leukemia?

They are usually males over the age of 40

Solid masses resulting from collections of leukemic cells are called...

Chloromas

What are the primary methods for diagnosing leukemia?

Peripheral blood examination and bone marrow studies

Whih two types of leukemias require cytogenic studies in order to identify the subtype?

AML and ALL

When there is no evidence of disease, the bone marrow and peripheral blood appear normal, this is called...

Complete remission

The term for when tumor cells cannot be detected by morphological examination but are detected via molecular testing...

Minimal residual

The term used when the patient has a lack of symptoms and a normal peripheral blood smear, but there is still evidence of the disease in the bone marrow....

Partial remission

Term used when a patient that has had leukemia has less than 1 in 10,000 blasts in the bone marrow...

Molecular remission

In some cases, a patient has a high WBC count (greater than 100,000) which places them at high risk for thromboses. To prevent this, patients are treated with...

Patients are treated with leukapheresis and hydroxyurea which reduces WBC counts.

What are the traditional stages of leukemia treatment?

Induction, Intensification, Consolidation and Maintenance

Which stage of leukemia treatment? Aggressive treatment to destroy leukemic cells in the tissues, peripheral blood and marrow. There is a risk of the patient becoming critically ill. During this stage, the nurse focuses on monitoring for neutropenia, thrombocytopenia or anemia and provides psychological support.

Induction

Which stage of leukemia treatment? High doses of the drugs given for several months, other drugs that work differently may be added.

Intensification

Which stage of leukemia treatment? Occurs once remission is achieved. Purpose is to eliminate any remaining leukemic cells that may have survived the other stages.

Consolidation

Which stage of leukemia treatment? Lower doses of the induction drugs given every 3-4 weeks over a prolonged period of time.

Maintenance

Which type of leukemia doesn't respond well to maintenance therapy?

AML, it is rarely administered if the patient has this type

Hematopoietic Stem Cell Transplantation (HSCT) involves the eradication of the patient's stem cells which are then replaced with a donor's. Explain the following terms to describe donor sources: Allogeneic- Autologous- Syngeneic-

Allogeneic-HLA matched sibling or volunteer donor Autologous-self donated via harvest prior to eradication Syngeneic-identical twin donation

Malignant neoplasms originating in the bone marrow and lymphatic strutures, the fifth most common form of cancer in the US...

Lymphoma

A malignant condition characterized by abnormal, giant, multinucleated cells called Reed-Sternberg cells...

Hodgkin's Lymphoma

When does Hodgkin's Lymphoma peak in incidence?

It is considered bimodal, it peaks between 15-30, then again after age 50

Where are the Reed-Sternberg cells associated with Hodgkin's lymphoma located?

In the lymph nodes

What are the three key factors for development of Hodgkin's Lymphoma?

Infection with the Epstein-Barr virus, genetic predisposition and exposure to environmental toxins

What organs are the most common sites of infiltration from Hodgkin's lymphoma (3)?

Spleen, liver and lungs

Which lymph nodes are the most common sites of Hodgkin's Lymphoma's initial development?

Cervical, axillary or inguinal lymph nodes. A mediastinal mass is the second most common area.

T/F The lymphadenopathy associated with Hodgkins lymphoma is typically freely moveable, painless and nontender.

True

A patient with Hodgkin's lymphoma may experience weight loss, fatigue, weakness, fever, chills, tachycardia or night sweats. They may also experience itching, coughing, dyspnea, stridor, dysphagia or pain after drinking alcohol. Of this list, what are the "B symptoms" that denote a worse prognosis for the patient? (3)

Weight loss, fever and night sweats (grouped together)

Which form of lymphoma (Hodgkin's or non-Hodgkin's)can involve B or T lymphocytes?

Non-Hodgkins

What are the symptoms associated with mediastinal involvement in Hodgkin's Lymphoma?

Cough, dyspnea, stridor, dysphagia from the increased pressure from lymph node enlargement on surrounding structures.

What is the definitive diagnostic test for Hodgkin's Lymphoma?

Excisional lymph node biopsies, they are used to detect the presence of Reed-Sternberg cells

What diagnostic tool is the most important for staging Hodgkin's Lymphoma?

A bone marrow aspiration/biopsy

Hodgkin's lymphoma is typically treated with varying durations of the ABVD chemotherapy protocol. What drugs are included in this regimen?

A-Adriamycin B-Bleomycin V-Vinblastine D-Dacarbazine

Patients in the advanced stages of Hodgkin's Lymphoma may be treated with the ABVD protocol and the MOPP protocol, alternating between the two. What drugs are included in the MOPP regimen?

M-Mechlorethamine O-Oncovin (vincristine) P-Procarbazine P-Prednisone

What are the common complications experienced by patients who have achieved remission of Hodgkin's lymphoma?

Secondary malignancies, endocrine, cardiac and/or pulmonary dysfunctions. Often these develop many, many years later

What are the three most common secondary malignancies experienced by patients who have had Hodgkin's lymphoma?

Acute myelogenous leukemia (AML), non-Hodgkin's lymphoma, and solid tumors.

Which patient has a better prognosis, the one with Hodgkin's Lymphoma or the one with Non-Hodgkin's Lymphoma?

The one with Hodgkin's. NHL has a poor prognosis due to its insidious, diffuse nature

Who is most likely to experience remission, the patient with an indolent form of Non-Hodgkin's Lymphoma or the person with an aggressive form of Non-Hodgkin's Lymphoma?

The person with the more aggressive form. It is more difficult to cause remission in a patient with the indolent form

Who is at most risk for developing multiple myeloma?

An African American, male, over age 40

What is the most common presenting symptoms of multiple myeloma?

Skeletal pain, namely in the ribs, pelvis or spine that is triggered by movement

What are the proteins that are screened for in a patient with suspected multiple myeloma?

M proteins/myeloma proteins. They are produced by the malignant cells.

How is the prognosis for multiple myeloma determined?

B2 microglobulins and albumin are measured. The higher the B2 or the lower the albumin, the worse the prognosis.

What is the underlying cause of most of the problems associated with multiple myeloma?

Hypercalcemia. It can cause renal and heart damage, seizures, coma, etc. The hypercalcemia is caused by the destruction of bone by the malignant cells.

What are the major nursing considerations for a patient with multiple myeloma?

Keep them hydrated to minimize problems with hypercalcemia. Urinary output should be between 1.5-2 L a day. This may require an intake of 3-4 L. Encourage weight bearing exercises. Corticosteroids may help excrete excess calcium. Electrolytes need to be monitored closely as well as kidney function. Hypercalcemia can cause kidney problems and the treatments can cause hyperuricemia which can also damage the kidneys (allopurinol is prescribed to help prevent this). In addition, the high pr

What do most patients with multiple myeloma die from?

Bacterial infections, you must monitor them closely for s/s of infection

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