(relates to chapter 31, “nursing management: hematologic problems,” in the textbook) copyright...

(Relates to Chapter 31, “Nursing Management: Hematologic Problems,” in the textbook)

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

• Malignant neoplasms originating in the bone marrow and lymphatic structures Result in the proliferation of lymphocytes

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 2

• Fifth most common type of cancer in the United States

• Two major types Hodgkin’s lymphoma Non-Hodgkin’s lymphoma (NHL)


• Malignant condition with Proliferation of abnormal giant, multinucleated cells▪ Reed-Sternberg cells▪ Located in the lymph nodes


• Bimodal age-specific incidence• 15 to 35 years of age• >50 years of age

Twice as prevalent in males as in females


• Cause remains unknown. • Key factors

Infection with Epstein-Barr virus

Genetic predisposition Exposure to occupational toxins


• Normal structure of lymph nodes destroyed by hyperplasia of monocytes and macrophages


• Main diagnostic feature Presence of Reed-Sternberg cells in lymph node biopsy specimens


• Believed to arise in a single location Spreads along adjacent lymphatics

Eventually infiltrates other organs▪ Lungs, spleen, or liver

• Two thirds of patients are affected first in the cervical lymph nodes.


• Disease begins above diaphragm. Remains in lymph nodes for variable amount of time

• Below the diaphragm Frequently spreads to extralymphoid sites


• Insidious onset• Enlargement of cervical,

axillary, or inguinal lymph nodes



Fig. 31-13. Hodgkin’s lymphoma (stage IIA). This patient has enlargement of the cervical lymph nodes.

• Nodes remain movable and nontender

• Painless unless nodes exert pressure on adjacent nerves


• May experience Weight loss, fatigue, weakness, fever, chills, tachycardia, or night sweats


• Initial symptoms correlate with worse prognosis Called B symptoms

▪ Fever▪ Night sweats▪ Weight loss


• Alcohol-induced pain • Generalized pruritus without

lesions


• Mediastinal node involvement is evident with Cough Dyspnea Stridor Dysphagia


• Advanced cases Hepatomegaly Splenomegaly Anemia Other physical signs vary, depending on disease location.


• Peripheral blood analysis• Excisional lymph node biopsy• Bone marrow examination• Radiologic evaluation


• Using diagnostic studies, a stage of disease is determined.

• Disease may be localized or diffuse.

• Treatment depends on the nature and extent of the disease.



Fig. 31-14. Staging system for Hodgkin’s lymphoma and non-Hodgkin’s lymphoma. Stage I, involvement of single lymph node (e.g., cervical node). Stage II, involvement of two or more lymph nodes on one side of diaphragm. Stage III, lymph node involvement above and below the diaphragm. Stage IV, involvement outside of diaphragm (e.g., liver, bone marrow). The stage is followed by the letter A (absence) or B (presence) to indicate significant systemic symptoms (e.g., fever, night sweats, weight loss).

• Nomenclature used in staging A or B classification

▪ Presence of symptoms when disease is found

Roman numeral (I to IV) ▪ Location and disease extent


• Management focuses on selecting a treatment plan. Least amount to achieve cure Minimize short- and long-term complications


• Combination chemotherapy Favorable early-stage disease, receive 2 to 4 cycles

Unfavorable early stage, receive 4 to 6 cycles

Advanced stage, receive 6 to 8 cycles


• Radiation as a supplement varies, depending on sites of disease and presence of disease after chemotherapy.


• Therapy must be aggressive.• Maintenance chemotherapy

does not contribute to increased survival once a complete remission has been achieved.


• Risk of secondary malignancies 2% to 6% Generally occur within the first 10 years


• Skin in radiation field needs attention.

• Psychosocial considerations

• Fertility issues• Overall better prognosis

than many cancers


• Heterogeneous group of malignant neoplasms of the immune system affecting all ages Primarily B- and T-cell origin


• Classified according to Different cellular characteristics

Lymph node characteristics• Varies from slow to rapid

disease progression


• Unknown cause• Most common in those who

have used immunosuppressive meds or have received chemotherapy or radiation

• No hallmark feature All NHLs involve lymphocytes arrested at various stages of development.


• Can originate outside lymph node

• Spread can be unpredictable.



Fig. 31-15. Non-Hodgkin’s lymphoma involving the spleen. The presence of an isolated mass is typical.

• Widely disseminated disease usually present at time of diagnosis

• Painless lymph node enlargement Primary clinical manifestation


• Patients with high-grade lymphomas Lymphadenopathy B symptoms


• Peripheral blood is usually normal. Some lymphomas manifest in “leukemic” phase.


• Similar to Hodgkin’s lymphoma

• Lymph node biopsy Establishes cell type and pattern


• Staging guides therapy.• Prognosis for NHL generally

is not as good as that for Hodgkin’s lymphoma.


• Treatment Chemotherapy Radiation therapy


• More aggressive lymphomas are more responsive to treatment. More likely to be cured


• Hematopoietic stem cell transplant

• Rituximab (Rituxan)• Ibritumomab tiuxetan

(Zevalin) • Tositumomab (Bexxar)


• Phototherapy• α-Interferon• Bexarotene (Targretin),

vorinostat (Zolinza), or denileukin diftitox (Ontak)


• Largely based on managing problems related to the disease, pancytopenia, and other side effects

• Must know about subtype and extent of disease


• Skin in the radiation field requires special attention.

• Psychosocial considerations• Fertility concerns


• 74-year-old man visits his primary care physician with gastrointestinal complaints.

• Enlarged nodes are noted on assessment.


• Blood work and a CT are ordered. Followed by a lymph node biopsy

• He is diagnosed with intermediate-grade, diffuse, large non-Hodgkin’s lymphoma.


1.What is his primary treatment option?

2.What other treatments may he receive?


3. What is the most important nursing care for him?


(relates to chapter 31, “nursing management: hematologic problems,” in the textbook) copyright...

Documents

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cervical lymph nodes

inguinal lymph nodescopyright

malignant neoplasms

adjacent lymphatics

hodgkins lymphoma stage

adjacent nervescopyright

bone marrow