Hematolymphatic, Immunological, and Oncological Care Plans

Chapter 10


Hematolymphatic, Immunological, and Oncological Care Plans


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Anemia


Iron Deficiency; Cobalamin (B12) Deficiency; Pernicious Anemia; Aplastic Anemia


Anemia is a general diagnostic term referring to a decrease in number or derangement in function of erythrocytes (red blood cells [RBCs]), and is the most common hematological disorder. Classification of the type of anemia begins with the complete blood count, with subsequent stepwise testing providing the actual diagnosis that guides treatment and prognosis. Three anemia classification strategies exist: cytometric, which measures the RBC mass and hemoglobin concentration; erythrokinetic, which measures RBC destruction and production; and biochemical, which looks at DNA. Cytometric measurements are easily measured and begin with evaluation of the mean corpuscular hemoglobin concentration (MCHC) and mean corpuscular volume (MCV). MCHC may be normocytic or hypochromic. MCV may be normocytic, macrocytic, or microcytic. The pattern of combination of these indexes classifies the anemia, directing the next sequence of blood work to assist in diagnosis and etiology of the anemia.



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Iron deficiency anemia is a hypochromic, microcytic anemia usually occurring over time, resulting from dietary deficiencies, poor absorption, chronic blood loss as seen in younger women with heavy menses or older persons with gastrointestinal (GI) loss from ulcer, use of nonsteroidal medications, or GI malignancy. Cobalamin, or B12, deficiency and pernicious anemia are both caused by deficiency of B12. Pernicious anemia impedes B12 absorption by lack of intrinsic factor in the stomach. Poor diet intake, certain medications, alcoholism, and some bowel disorders can cause cobalamin deficiency, resulting in this macrocytic anemia.


Aplastic anemia is a disease of diverse causes characterized by a decrease in precursor cells in the bone marrow and replacement of the marrow with fat. Aplastic anemia is characterized by pancytopenia, depression of all blood elements: white blood cells (leukopenia), RBCs (anemia), and platelets (thrombocytopenia). The underlying cause of aplastic anemia remains unknown. Possible pathophysiological mechanisms include certain infections, toxic dosages of chemicals and drugs, radiation damage, and impairment of cellular interactions necessary to sustain hematopoiesis. Advances in bone marrow transplantation and immunosuppressive therapy have significantly improved outcomes. This care plan focuses on ongoing care in the ambulatory care setting.




Cancer Chemotherapy


Cancer chemotherapy is the administration of cytotoxic drugs by various routes for the purpose of destroying malignant cells. Chemotherapeutic drugs are commonly classified according to their antineoplastic action: alkylating agents, antitumor antibiotics, antimetabolites, vinca alkaloids, and hormonal agents. Another way of classifying cancer chemotherapeutic agents is based on where in the cancer cell’s life cycle the drug has its effect. Cell cycle–specific drugs exert their cytotoxic effect at a specific point in the cell cycle. Drugs that affect the cancer cell at any point in its cycle are called cell cycle–nonspecific drugs. These drugs are dose dependent in their therapeutic effect. Typically a combination of chemotherapeutic agents is administered to destroy the greatest number of tumor cells at different stages of cell replication. Cancer chemotherapy may be administered in the hospital, ambulatory care, or even home setting. It is recommended by the Oncology Nursing Society that chemotherapy, biotherapy, and targeted therapies be administered by a qualified chemotherapy-competent nurse. Depending on the specific cancer, cell type, cellular mutations, and stage of disease, newer targeted therapies or biotherapies may be administered along with chemotherapy. The goal of systemic treatment is cure, control, or symptom relief. It is often used as an adjunct to surgery and radiation. Because chemotherapy drugs are highly toxic and are given systemically, they affect normal cells as well as cancer cells. Most of the side effects of cancer chemotherapy are the result of the drugs’ effects on rapidly dividing normal cells in the hair follicles, the gastrointestinal tract, and the bone marrow. The Oncology Nursing Society has developed evidence-based resources for patients experiencing chemotherapy-related side effects.




Cancer Radiation Therapy


External Beam; Brachytherapy; Teletherapy


Radiation therapy is the use of ionizing radiation delivered in prescribed doses to a malignancy. Ionizing radiation interacts with the atoms and molecules of malignant cells, interfering with mitotic activity, thereby causing DNA damage. This damage interferes with the malignant cell’s ability to reproduce. Adjacent healthy cells experience the same detrimental effects, however, resulting in untoward side effects from radiation therapy. Radiation therapy may be curative of some cancers, or it may be used as a palliative treatment to reduce the pain and pressure from large tumors. Radiation may be used alone or in combination with other treatment modalities such as surgery, chemotherapy, and/or biotherapy.


Radiation therapy can be divided into two broad categories: external radiation, also known as teletherapy, and internal radiation, commonly known as brachytherapy. Teletherapy administers a prescribed dosage of radiation at a distance from the patient using a machine, such as a linear accelerator. Brachytherapy is the implantation of either sealed (solid) or unsealed (fluid) radioactive sources. The sealed radioactive implant may be contained within an applicator, needle, or seed, and is placed in or near the malignancy. The unsealed radioactive isotope can be administered through the intravenous or oral route or by instillation into a specific body cavity.


The radiation oncologist prescribes the treatment modality and amount of treatment necessary. This treatment plan is based on the location, size, and biological characteristics of the malignancy. The patient’s health history, current health status, and previous cancer treatments are taken into consideration in treatment planning. All health care providers need to implement principles of radiation safety when caring for patients undergoing radiation therapy.




Disseminated Intravascular Coagulation


Coagulopathy; Defibrination Syndrome; DIC


Disseminated intravascular coagulation (DIC) is a coagulation disorder that prompts overstimulation of the normal clotting cascade and results in simultaneous thrombosis and hemorrhage. The formation of microclots affects tissue perfusion in the major organs, causing hypoxia, ischemia, and tissue damage. Coagulation occurs in two different pathways: intrinsic and extrinsic. These pathways are responsible for formation of fibrin clots and blood clotting, which maintains hemostasis. In the intrinsic pathway, endothelial cell damage commonly occurs because of sepsis or infection. The extrinsic pathway is initiated by tissue injury such as from malignancy, trauma, or obstetrical complications. DIC may present as an acute or chronic condition. The medical management of DIC is primarily aimed at: (1) treating the underlying cause, (2) managing complications from both primary and secondary causes, (3) supporting organ function, and (4) stopping abnormal coagulation and controlling bleeding. Morbidity and mortality depend on underlying cause and severity of the coagulopathy.




Hematopoietic Stem Cell Transplantation


Bone Marrow Transplant; Peripheral Blood Stem Cell Transplant


Bone marrow transplantation (BMT) and peripheral blood stem cell transplantation (PBSCT) are terms that now more commonly fall under the umbrella term of hematopoietic stem cell transplantation (HSCT). The indications for HSCT are expanding; it is used as both a curative and investigational treatment for both malignant and nonmalignant conditions. HSCT should not be confused with the controversial field of embryonic stem cells. Embryonic stem cells, derived from fertilized embryos, are undifferentiated cells that have the ability to form any adult cell. Hematopoietic stem cells are the “mother” cells that differentiate only into the cells of the blood system (e.g., white blood cells [WBCs], red blood cells [RBCs], platelets).


HSCT is used to replace diseased bone marrow, as a hematopoietic rescue after high-dose therapy (radiation or chemotherapy), as a form of immunotherapy, and as a vehicle for gene therapy.


There are three major types of transplants:




There are three sources of hematopoietic stem cells:




There is one other classification of transplant based on the amount and type of pretransplant therapy that is administered. Standard transplants use strong treatment (chemotherapy and/or radiation therapy) administered before transplantation to destroy the host’s diseased cells and suppress the host’s immune system. This therapy is referred to as ablative therapy, because it eliminates all host blood and immune cells. Reduced-intensity transplants—also called nonmyeloablative transplants or minitransplants—are transplants that use less intense treatment to prepare for transplantation than a standard transplant does. Thus the doses of chemotherapy given before transplantation are much lower and do not necessarily eliminate all diseased cells. This type of transplant is only used in the allogeneic setting, because this method relies on the donor’s immune cells to fight disease. This care plan focuses on inpatient care. Emotional issues related to HSCT are not addressed here.




Human Immunodeficiency Virus


Acquired Immunodeficiency Syndrome (AIDS)


Human immunodeficiency virus (HIV) causes acquired immunodeficiency syndrome (AIDS). Transmission of HIV occurs in situations that allow contact with body fluids that are infected with the virus. The primary body fluids associated with transmission are blood, vaginal secretions, semen, and breast milk. Transmission of HIV can occur during sexual intercourse with an infected partner. Transmission through blood and blood product administration occurred early in the history of HIV in the United States. With current methods for screening blood donors and testing donated blood before transfusion, this is no longer considered a route of infection transmission. However, contact with infected blood through shared IV equipment and accidental needle sticks is still possible. Perinatal transmission of the virus from mother to baby is thought to occur during pregnancy, during delivery, or through breast-feeding. Most of the early victims of the syndrome were homosexual men; however, in many cities today, infected IV drug users, their sexual partners, and their children outnumber infected homosexual men. Despite efforts to increase routine, voluntary testing and counseling for HIV, many patients first learn that they are infected after their disease is advanced.


The first signs of HIV infection occur when the body produces HIV antibodies. Flulike signs and symptoms that may last 1 to 2 weeks characterize this stage of the infection. After this stage, the patient may be asymptomatic for acute infection, depending on his or her general state of health. This asymptomatic stage can last 10 years or longer. When the immune system begins to fail, the patient exhibits signs of immune system incompetence. The patient begins to develop clinical conditions such as cancers and opportunistic infections. When the patient’s CD4 lymphocyte count falls below 200, AIDS is diagnosed. Patients present at various stages of the disease. Treatment regimens are changing rapidly. Patients are treated in hospital, ambulatory care, and home care settings. People may receive prophylactic antiretroviral therapy following high-risk, unprotected sex or injection drug exposures. The nursing diagnosis list of problems for various stages of HIV infection and AIDS is extensive. Some are highlighted here.


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Dec 3, 2016 | Posted by in NURSING | Comments Off on Hematolymphatic, Immunological, and Oncological Care Plans

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