The student will:
- Understand and discuss the pathophysiology and causes of common white blood cell (WBC) disorders.
- Understand and discuss diagnostics used to identify WBC disorders.
- Understand treatment and nursing care of selected WBC disorders.
WHITE BLOOD CELLS (WBC) FUNCTIONS
Neutrophils:
- Kill bacteria, fungi, and foreign debris.
Monocytes:
- Clean up damaged cells.
Eosinophils:
- Kill parasites, cancer cells, and are involved in allergic response.
Lymphocytes:
- Help fight viruses and make antibodies.
Basophils:
- Involved in allergic response.
CHEMOTHERAPY
Definition:
- Use of chemicals to kill rapidly growing abnormal or cancerous cells in the body.
Types:
- Many different types of chemotherapy exist.
Duration:
- Each course typically takes 3-6 months.
- Can be administered intravenously (IV) or orally (PO).
Outcomes:
- Can be a cure for some cancers.
GOALS OF CHEMOTHERAPY
Primary Goal:
- Destroy cancer cells.
Risk:
- Greatest risk for infection occurs 7-10 days after starting (Nadir period).
Phases of Chemotherapy:
- Induction:
- Goal: Destroy remaining cancer cells.
- Lasts several months.
- Post-induction:
- Goal: Maintain remission.
- Maintenance:
- Focus on avoiding disease resurgence.
EFFECTS OF CHEMOTHERAPY ON THE BODY
Side effects may include:
- Pain
- Trouble breathing
- Hair loss
- Mouth sores
- Weakened immune system
- Nausea
- Vomiting
- Constipation
- Diarrhea
- Bruising
- Bleeding
- Neuropathy
- Rashes
NURSING CARE FOR PATIENTS UNDERGOING CHEMOTHERAPY
Nutritional support:
- Dietary consult for appropriate nutrition.
Medications:
- Megestrol and dronabinol for appetite stimulation.
- Use of Ulcerease (mouth rinse) for mouth sores.
- Ondansetron for nausea/vomiting.
Monitor for infection:
- Infection is a leading cause of death in cancer patients.
- Common sites of infection include lungs, gastrointestinal (GU) system, mouth, rectal area, peritoneal cavity, and blood (septicemia).
- Advise patients at risk for neutropenia to contact healthcare provider (HCP) if temperature exceeds 100.4°F (38°C).
Use of Filgrastim:
- A bone marrow stimulant to boost WBC production.
NEUTROPENIA
Definition:
- Absolute Neutrophil Count (ANC) less than 1000 cells/mm³ (or 1 × 10⁹/L).
Clinical Manifestations:
- Fever (may be low grade).
- Sore throat and oral lesions.
- Diarrhea.
- Non-productive cough.
Diagnostics:
- WBC with differential.
- Leukopenia: normal count is 4,000.
- ANC classifications:
- Mild to moderate: 1000-500 cells/mm³.
- Severe: less than 500 cells/mm³.
TREATMENT AND NURSING CARE FOR NEUTROPENIA
Infection risk monitoring:
- Symptoms to watch for:
- Fever >100.4°F.
- Oral lesions, sore throat, etc.
Laboratory Tests:
- Monitor ANC levels.
Treatment:
- Blood cultures to detect infections if fever presents.
- Start antibiotic therapy within 1 hour if infection is suspected.
- Use of Filgrastim as a treatment option.
NEUTROPENIC PRECAUTIONS
Visitor Policy:
- Visitors must announce themselves to the nurse before entering the room.
Handwashing Requirements:
- Strict hand hygiene before patient care.
Room Maintenance:
- Private room with a closed door.
- No fresh fruits, vegetables, or flowers allowed.
- No visitors or staff with infectious illnesses.
Articles Leaving Room:
- No special precautions for items leaving the room.
- No sick visitors or personnel allowed.
LEARNING CHECK EXAMPLE
The following situation requires nursing intervention:
- C. The client’s grandson who is being treated for strep throat visits.
LEUKEMIA
Definition:
- A group of malignant disorders characterized by abnormal leukocyte production.
Epidemiology:
- 2019 estimates indicated 61,780 new cases with 22,840 deaths.
Acute Leukemia:
- Abrupt onset and rapid progression.
- Types:
- Acute myeloid leukemia (AML):
- Comprises 80% of acute leukemias in adults.
- Acute lymphocytic leukemia (ALL):
- Most common type of leukemia in children.
Chronic Leukemia:
- Gradual onset and persistent progression.
- Types:
- Chronic myelogenous leukemia (CML).
- Chronic lymphocytic leukemia (CLL):
- Most common leukemia in adults.
- Note: Memorization of details is not necessary.
LEUKEMIA DIAGNOSTICS
Diagnostics:
- Complete blood count (CBC) with differential.
- Peripheral blood smear.
- Bone marrow biopsy.
- Lumbar puncture for staging classification.
LYMPHOMA
General Overview:
- Incudes Hodgkin and Non-Hodgkin lymphoma.
- Involves lymphatic system components including lymphatics, lymph nodes, thymus gland, bone marrow, and spleen.
HODGKIN LYMPHOMA
Characteristics:
- Genetic, environmental, and Epstein-Barr virus contributions.
- Lymph node malignancy characterized by the presence of Reed Sternberg Cells.
Demographics:
- More common in age groups 15-30 years and after 55.
Clinical Manifestations:
- Cervical lymph node enlargement.
- Weight loss and fatigue.
- Symptoms like fever, cough, and dysphagia.
- B symptoms (drenching night sweats; weight loss >10% in 6 months; fever >100.4° F).
- Pain at the disease site after consuming small amounts of alcohol (requires medical attention).
NON-HODGKIN LYMPHOMA
Characteristics:
- Begins in lymphocytes without the presence of Reed Sternberg cells.
Incidence:
- Most common blood cancer.
- Linked to previous infections, notably H. pylori.
CLINICAL MANIFESTATIONS OF NON-HODGKIN LYMPHOMA
Painless lymph node enlargement.
Non-specific symptoms may include hepatomegaly, airway obstruction, and gastrointestinal symptoms.
Involvement in various areas of the body: tonsils, neck, thymus area, armpit, diaphragm, spleen, abdominal, pelvic, and groin areas.
NON-HODGKIN LYMPHOMA DIAGNOSTICS
Diagnostics:
- Lymph node biopsy for confirmation.
- Nursing considerations include infection and bleeding risks.
- PET scan for staging purposes.
STAGING OF LYMPHOMA
Stages:
- I: Above diaphragm
- II: Below diaphragm
- III: Involvement on both sides of the diaphragm
- IV: Disseminated disease.
TREATMENT OF LYMPHOMA
Stage I and II:
- External beam radiation.
Later stages:
- Chemotherapy with additional treatments based on disease severity.
NURSING CARE FOR LYMPHOMA PATIENTS
Pain management:
- Use NSAIDs, opioids, and corticosteroids as necessary.
Infection monitoring and management:
- Careful assessment due to compromised immune systems.
Risk of bleeding:
- Regular monitoring of blood counts and bleeding signs.
Psychosocial support needed:
- Essential due to increased vulnerability during treatment.
MULTIPLE MYELOMA
Definition:
- A malignancy of the plasma B cells.
Etiology:
- Genetic predispositions, toxins, and viral exposure.
Demographics:
- Men are affected more than women.
Survival Rate:
- 5-year survival rate is approximately 45%.
- Viral infections, such as HIV, may elevate the risk of developing multiple myeloma.
CLINICAL MANIFESTATIONS OF MULTIPLE MYELOMA
Disease often develops slowly with insidious onset; symptoms may not appear until advanced.
Notable symptoms include:
- Bone pain and fractures.
- Fatigue, weakness, and numbness.
- Kidney dysfunction.
- Hypercalcemia and hyperuricemia.
- Increased risk of bleeding and infections due to poor bone marrow function.
DIAGNOSTICS AND TREATMENT OF MULTIPLE MYELOMA
Diagnostics:
- CBC showing pancytopenia.
- CMP with increased calcium and high serum creatinine.
- Urinalysis demonstrating the presence of Bence Jones Protein.
- Bone marrow biopsy confirms diagnosis.
Treatment options:
- Chemotherapy and corticosteroids.
- Multiple myeloma is seldom cured, but treatment can relieve symptoms and prolong survival.
- Goals of management include pain control and preventing fractures.
NURSING CARE FOR MULTIPLE MYELOMA PATIENTS
Monitoring:
- Infection risk and bleeding risk management.
- Administration of IV fluids to maintain urine output at 1.5 to 2 L/day.
- Use of IV furosemide for kidney protection.
- Bisphosphonates (e.g., alendronate) may be useful.
Ambulation:
- Encourage weight-bearing activities to help bones resorb calcium, preventing hypercalcemia.
Patient Safety:
- High risk for falls due to potential pathologic fractures.