Malignant Hematologic Disorders

leukemia

cancer of blood-forming tissues, causing abnormal WBCs to crowd out normal bone function

• infection risk- implement neutorpenic precautions, monitor fever, and teach meticulous hand hygiene

• bleeding risk- thrombocytopenia causes spontaneous bleeding from any site

  • soft bristle toothbrush, electric razor, avoid invasive procedures when platelets are low

    • transfuse platelets when < 10,000 or if active bleeding occurs

• tumor lysis syndrome- aggressive hydration, allopurinol prophylaxis, and close metabolic monitoring are essential

lymphoma (hodgkin or non-hodgkin)

cancer originating in the lymphatic system

• s/s: fever (cyclical, called pel- ebstein fever), night sweats (drenching, requiring clothing change), unexplained weight loss (> 10% in 6 months)

• mediastinal mass complications

  • mediastinal lymph nodes, creating a bulky mass in the chest

    • airway compression (life-threatening), superior vena cava syndrome, persistent cough, dyspnea, especially when lying flat, chest pain

multiple myeloma

cancer of plasma cells in bone marrow, causing overproduction of abnormal antibodies and destruction of bone

• calcium elevates- bone destruction releases calcium into the bloodstream

• renal failure- monitor creatinine and urine output closely

• anemia- causes severe fatigue, limiting quality of life

• bone lesions- lytic bone lesions cause pathologic fractures, severe pain, and spinal cord compression risk

multiple myeloma key nrusing actions nursing

• aggressive hydration- push oral fluids 3- 4 L daily, IV hydration if unable to maintain

• fall prevention- weakened bones fracture easily, even with minimal trauma

• infection control- abnormal antibodies fail to fight infection effectively

• pain management- bone pain is severe and constant (around-the-clock opioid analgesia and adjuvant medications)

somatic (nociceptive pain)

well localized pain from skin, bone, muscle, or connective tissue damage

• aching, throbbing, or sharp

  • ex: bone metases, post surgical pain, tumor pressing on structures

visceral (nocicpeptive pain)

poorly localized deep, squeezing, or pressure like pain from internal organ

• may be referred to distant sites

  • ex: liver capsule distention, bowel obstruction, pancreatic cancer

neuropathic pain

burning, shooting, electric, or tingling pain from nerve damage

• often includes allodynia (pain from non-painful stimuli)

  • ex: chemotherapy-induced neuropathy, tumor invasion of nerve plexus

breakthrough pain

sudden, severe pain that “breaks through” baseline analgesia

• may be predictable (incident pain with movement) or unpredictable

  • requires immediate release opioid for rapid relief

analgesic pain ladder

• step 1: mild pain (1-3/10)

  • non-opioid analgesics- acetaminophen, NSAIDs

    • add adjucant medicaiton as needed (for neuropathic pain, add gabapentin or duloxetine)

• step 2: moderate pain (4-6/10)

  • opiods for moderate pain- codeine, tramadol, hydrocodone

• step 3: severe pain (7-10/10)

  • strong opiods- morphine, hydromorphone, fentanyl, oxycodone, methadone

opiod management

gold standard for severe cancer pain

• respiratory rate- hold if < 12 per min and notify provider

• blood pressure- can cause hypotension, especially with IV administration

• sedation level- assess using scale before respiratory depression occurs

• pain relief- reassess effectiveness after appropriate interval

• common side effects:

  • constipation, nausea, sedation, pruritis

equianalgesic dosing

when converting between opioids, use equianalgesic tablets to calculate equivalent doses, always reduce the calculated dose by 25- 50% when switching opioids to account for incomplete cross tolerance

sedation levels

• sedation alone (level 1-2): monitor closely but usually safe, patient may be catching up on sleep after nights of uncontrolled pain

• sedation level 3: reduce opioid use, increase monitoring frequency, notify provider

• sedation level 4 OR respiratory rate < 8-10/ min: hold opioid, stimulate patient, prepare naloxone, call rapid response if no improvement

palliative care

specialzied medical care on relief from symptoms and stress of serious illness

• can occur at any stage of disease, even alongside treatment

  • goal is improving quality of life for patient and family

hospice care

specialized form of palliative care for patient with terminal illness and prognosis of 6 months or less if the disease follows expected course

• curative treatment is stopped, focus shifts entirely to comfort and quality of remaining time

advance directives

legal documents specifying patients wishes for medical care if unable to speak for themselves

• include living will and durable power of attorney for healthcare

  • DNR, DNI, and comfort measures are types of orders, not advance directives

living will

a legal document outlining specific medical treatment a patient does or does not want to receiveparticularly if they become incapacitated, particurarly at the end of life

healthcare proxy

designates a trusted person (agent or surrogate) to make healthcare decisions on the patient’s behalf when they are unable to

• this person interprets the patient’s values and makes choices, not just for end of life, but for all medical situations

informed consent

a process ensuring a patient understands the nature of a medical procedure or treatment, its risks, benefits, alternatives, and agrees voluntarily to treatment

• the physican is responsible for providing information, the nurse ensures consent is obtained and clarifies questions

end of life care nursing prioritiesend-of-life

• physical comfort- aggressive symptoms management, pain, dyspnea, nausea, anxiety, mouth care for dry mucous membranes

• psychological support- address fears, complete unfinished business, say goodbyes

• family support- explain what to expect as death approaches, teach how to provide comfort measures

• ethical decison making- respect advance directives and patient autonomy