Exam 3 PATHO

Leukemia- Are a group of hematological malignancies involving abnormal overproduction of leukocytes usually at an immature stage in the bone marrow

Lymphocytic leukemia involves abnormal cells from the lymphoid pathway

Myelocytic or myelogenous involves abnormal cells from the myeloid pathways

acute leukemia has a sudden onset

Chronic leukemia has a slow onset and persistent symptoms over a period of years

Acute lymphocytic leukemia

—mostly lymphoblasts present in bone marrow

—age of onset is younger than 15 years

Acute Myelogenous leukemia

— Mostly myeloblasts present in bone marrow

—age of onset is between 15 and 39 years old

Chronic myelogenous leukemia

— Mostly granulocytes present in bone marrow

—age of onset is in the fourth decade

Chronic lymphocytic leukemia

— mostly lymphocytes present in bone marrow

— Age of onset is after 50

Leukemia affects the bone marrow,

causing: anemia, Leukopenia, the production of immature cells, Thrombocytopenia, and a decline in immunity

The cause of leukemia is unknown and appears to involve gene damage of cells which leads to the transformation of cells from a normal state to a malignant state

Risk factors of leukemia include genetic viral immunological And environmental factors and exposure to radiation chemicals, and medication, such as previous chemotherapy

Assessment of leukemia

1. anorexia, fatigue, weight loss, weakness

2. Anemia

3. Overt bleeding, (which is nosebleeds gum, bleeding, rectal bleeding, hematuria increase menstrual flow) and occult bleeding (As detected in fecal occult blood test)

4. Ecchymosis, petechiae

5. Prolonged bleeding after minor abrasions or lacerations

6. Elevated temperature

7. Enlarged lymph nodes, spleen, liver

8. Palpitations, tachycardia, orthostatic, hypertension

9. Pallor and dyspnea on Exertion

10. Headache

11. Bone pain and joint swelling

12. Normal elevated or reduced white blood cell count

13. Decreased hemoglobin and hematocrit levels

14. Decreased platelet count

15. Positive bone marrow biopsy, identifying leukemic, blast phase cells

Infection

1. Infection can occur through auto contamination or cross-contamination. The white blood cell count may be extremely low during the period of greatest bone marrow depression known as the Nadir

2. Common sites of infection are the skin, respiratory tract and gastrointestinal tract

3. Initiate protective isolation procedures

4. Ensure frequent and thorough handwashing by the client, family and healthcare providers

5. Staff and visitors with known infections or exposure to communicable diseases should avoid contact with a client until risk of infectious spread has passed

6. Use strict septic technique for all procedures

7. Keep supplies for the client separate from supplies for other clients. Keep frequently used equipment in the room for the Clients use only

8. Limit the number of staff entering the clients room, reducing the number of staff who come into contact with the client reduces the risk of cross Infection

9. Maintain the client in a private room with the door closed

10. Place the client in a room with high efficiency, particularly air filtration or a laminar airflow system If possible

11. Reduce exposure to environmental organisms by thoroughly washing or eliminating fresh or raw fruits and vegetables from the diet eliminate fresh flowers and live plants from the clients room and avoid leaving standing water in the Client’s room

12. Be sure that the client’s room is cleaned daily

13. Assist the client with daily bathing, using an antimicrobial soap

14. Assist the client to perform oral hygiene frequently

15. Initiate a bowel program to prevent constipation and prevent rectal trauma

16. Avoid invasive procedure such as injections, rectal temperatures and urinary catheterization

17. Change wound dressings daily and inspect the wounds for redness, swelling, or drainage

18. Assess the urine for cloudiness and other characteristics of infection

19. It says skin and oral mucus membranes for signs of infection

    • Inspect the mouth daily

    • Offer complete mouth care before and after every meal and at Bedtime

    • Brush the teeth and tongue with a soft bristle, toothbrush or sponges

    • Provide mouth rinses every 12 hours with the prescribed solution

    • Administer topical anesthetic agents to Mouth sores as prescribed

    • Avoid the use of alcohol or glycerin based mouthwashes or swabs because they are irritating to the mucosa

    • Offer soft foods that are cool to warm in temperature rather than foods that are hard or spicy

20. Auscultate lung sounds and encourage the client to cough and deep breathe

21. Monitor temperature, pulse, respirations blood pressure and for pain

22. Monitor white blood cell and neutrophil counts

23. Notify the physician if signs of infection are present and prepared to obtain specimens for culture of the blood open lesions urine and sputum chest radiograph may also be prescribed

24. Administer prescribed antibiotic, antifungal, and antiviral medications

25. Instruct the client to avoid crowds in those with infections

26. Instruct the client about a low bacteria diet

27. Instruct the client to avoid activities that expose the client to infection such as changing a pet’s litter box or working with house plants or in the garden

28. Instruct the client that neither they nor their household contacts should receive immunization with a live virus such as measles, mumps, rubella, polio, varicella, shingles, and some influenza, including H1N1 vaccine

INFECTION IS A MAJOR CAUSE OF DEATH IN THE IMMUNOSUPPRESSED CLIENT

Bleeding

1. During the period of the greatest bone marrow suppression the platelet count may be extremely low

2. The client is at risk for bleeding when the platelet count falls below 50,000/MM3 and spontaneous bleeding frequently occurs when the platelet count is fewer than 20,000/MM3

3. Clients with platelet clowns lower than 20,000/MM three may need a platelet transfusion

4. For clients with anemia and fatigue, packed red blood cells may be prescribed

5. Monitor laboratory values

6. Examine the client for signs and symptoms of bleeding, examine all body, fluids, and excrement for the presence of blood

7. Handle the client gently; use caution when taking blood pressures to prevent skin injury.

8. Monitor for signs of internal hemorrhage (e.g., pain, rapid and weak pulse, increased abdominal girth, and abdomen guarding).

9. Provide soft foods that are cool to warm to avoid oral mucosa damage.

10. Avoid injections, if possible, to prevent trauma to the skin and bleeding; apply firm and gentle pressure to a needle stick site for at least 5 minutes, or longer if needed.

11. Pad side rails and sharp corners of the bed and furniture.

12. Avoid rectal suppositories, enemas, and thermometers.

13. If the female client is menstruating, count the number of pads or tampons used.

14. Administer blood products as prescribed.

15. Instruct the client to use a soft toothbrush and avoid dental floss.

16. Instruct the client to use only an electric razor for shaving.

17. Instruct the client to avoid blowing the nose.

18. Discourage the client from engaging in activities involving the use of sharp objects; contact sports also need to be avoided.

19. Instruct the client to avoid using non-steroid anti-inflammatory drugs and products that contain aspirin.

Fatigue and nutrition

1. Assist the client in selecting a well-balanced diet.

2. Provide small, frequent meals (high calorie, high protein, high carbohydrate) that require little chewing to reduce energy expenditure at mealtimes.

3. Assist the client in self-care and mobility activities.

4. Allow adequate rest periods during care.

5. Do not perform activities unless they are essential; assist the client in scheduling important or pleasurable activities during periods of highest energy.

6. Administer blood products for anemia as
   prescribed

Additional interventions

1. Chemotherapy

1. Induction therapy is aimed at achieving a rapid, complete remission of all manifesta-tions of the disease.

2. Consolidation therapy is administered early in remission with the aim of cure.

3. Maintenance therapy may be prescribed for months or years following successful induc-tion and consolidation therapy; the aim is to maintain remission.

1. Administer antibiotic, antibacterial, antiviral, and antifungal medications as prescribed.

2. Administer colony-stimulating factors as prescribed.

3. Administer blood replacements as prescribed.

4. Maintain infection and bleeding precautions.

5. Prepare the client for transplantation if indicated.

6. Instruct the client in appropriate home care measures.

7. Provide psychosocial support and support services for home care.

LYMPHOMA: HODGKIN’S DISEASE

Lymphomas, classified as Hodgkin's and non-Hodgkin's depending on the cell type, are characterized by abnormal proliferation of lymphocytes.

1. Hodgkin's disease is a malignancy of the lymph nodes that originates in a single lymph node or a chain of nodes.

2. Metastasis occurs to other adjacent lymph structures and eventually invades nonlymphoid tissue.

3. The disease usually involves lymph nodes, tonsils, spleen, and bone marrow and is characterized by the presence of Reed-Sternberg cells in the nodes.

4. Possible causes include viral infections; clients treated with combination chemotherapy for Hodgkin's disease have a greater risk of developing acute leukemia and non-Hodgkin's lym-phoma, among other secondary malignancies.

5. Prognosis depends on the stage of the disease.

Assessment

1. Fever

2. Malaise, fatigue, and weakness

3. Night sweats

4. Loss of appetite and significant weight loss

5. Anemia and thrombocytopenia

6. Enlarged lymph nodes, spleen, and liver

7. Positive biopsy of lymph nodes, with cervical nodes most often affected first

8. Presence of Reed-Sternberg cells in nodes

9. Positive computed tomography (CT) scan of the liver and spleen

Interventions

1. For earlier stages (stages I and II), without mediastinal node involvement, the treatment of choice is extensive external radiation of the involved lymph node regions.

2. With more extensive disease, radiation and mul-tiagent chemotherapy are used

3. Monitor for side effects related to chemotherapy or radiation therapy.

4. Monitor for signs of infection and bleeding.

5. Maintain infection and bleeding precautions.

6. Discuss the possibility of sterility with the male client receiving radiation, and inform the client of fertility options such as sperm banking.

MULTIPLE MYELOMA

1. A malignant proliferation of plasma cells within the bone

2. An excessive number of abnormal plasma cells invade the bone marrow and ultimately destroy bone; invasion of the lymph nodes, spleen, and liver occurs.

3. The abnormal plasma cells produce an abnormal antibody (myeloma protein or the Bence Jones protein) found in the blood and urine.

4. Multiple myeloma causes decreased production of immunoglobulin and antibodies and increased levels of uric acid and calcium, which can lead to renal failure.

5. The disease typically develops slowly and the cause is unknown.

Assessment

1. Bone (skeletal pain, especially in the ribs, spine, and pelvis

2. Weakness and fatigue

3. Recurrent infections

4. Anemia

5. Urinalysis shows Bence Jones proteinuria and elevated total serum protein level.

6. Osteoporosis (bone loss and the development of pathological fractures)

7. Thrombocytopenia and leukopenia

8. Elevated calcium and uric acid levels

9. Renal failure

10. Spinal cord compression and paraplegia

11. Bone marrow aspiration shows an abnormal number of immature plasma cells.

! The client with multiple myeloma is at risk for pathological fractures. Therefore provide skeletal support during moving, turning, and ambulating and provide a hazard-free environment.

Interventions

1. Administer chemotherapy as prescribed.

2. Provide supportive care to control symptoms and prevent complications, especially bone fractures, hypercalcemia, renal failure, and infections.

3. Maintain neutropenic and bleeding precautions as necessary.

4. Monitor for signs of bleeding, infection, and skeletal fractures.

5. Encourage at least 2 L of fluids per day to offset potential problems associated with hypercalce-mia, hyperuricemia, and proteinuria, and encourage additional fluid as indicated and tolerated.

6. Monitor for signs of renal failure.

7. Encourage ambulation to prevent renal problems and to slow down bone resorption.

8. Administer IV fluids and diuretics as prescribed to increase renal excretion of calcium.

9. Administer blood transfusions as prescribed for anemia.

10. Administer analgesics as prescribed and provide nonpharmacological therapies to control pain.

11. Administer antibiotics as prescribed for infection.

12. Prepare the client for local radiation therapy if prescribed.

13. Instruct the client in home care measures and the signs and symptoms of infection.

14. Administer bisphosphonate medications as prescribed to slow bone damage and reduce pain and risk of fractures.