9/13/2014

Circulatory System

Anatomy & Physiology

Beryl Ben C. Mergal, RN, MSN

Myelodysplastic Syndrome
Pathophysiology
MDS is a stem cell disorder in which the stem
cells fail to reproduce and differentiate into the
various type of blood cells.
The genetic components of stem cells (DNA &
mitochondria) are altered.
The bone marrow loses its ability to produce
normal cells, instead producing abnormal
(dysplastic) cells.

Myelodysplastic Syndrome

Myelodysplastic Syndrome

Manifestations
Anemia (early)
Fatigue
Weakness
Dypnea
Pallor

Treatment
Bone marrow transplant
Supportive therapy
Chemotherapy
Iron chelation therapy removal of excess iron in
the body using the drug desferrioxamine
(desferal).

Myelodysplastic Syndrome

Myelodysplastic Syndrome

Interventions

Interventions

Monitor for signs of anemia such as fatigue, dyspnea,

dizziness and headaches
Monitor for early signs of infection, and for signs of active
bleeding
During blood transfusion, monitor vital signs and adverse
reactions to the BT.
Encourage adequate fluid intake to replace fluid loss, and
ensure renal function.
Encourage exercise and adequate hydration to prevent
constipation or diarrhea

Monitor for alarming signs such as

Fever or chills
Sudden onset of shortness of breath or chest pain
Skin changes such as bruises or rash
Headaches or confusion
Bleeding from hemoptysis, hematuria, or other signs of active
bleeding

For fatigue, manage activities and energy conservation,

promote rest, and assess for risk of injury or fall.
For quality of life and end of life care.

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Polycythemia (Polycythemia
Vera)

Polycythemia (Polycythemia
Vera)

Primary Polycythemia
It is a neoplastic stem cell disorder characterized
by overproduction of RBCs and to a lesser extent,
white blood cells and platelets.
It is classified as a myeloproliferative disorder.
Secondary Polycythemia (erythrocytosis)
Increased number of RBCs in response to excess
erythropoietin secretion or prolonged hypoxia.

Manifestations (Primary Polycythemia)

Polycythemia (Polycythemia
Vera)

Polycythemia (Polycythemia
Vera)

Manifestations (Secondary Polycythemia)

Nursing Care

Same with primary polycythemia but without splenomegaly.

Polycythemia (Polycythemia
Vera)

Polycythemia (Polycythemia
Vera)

Intervention

Treatment
focus on reducing the amount of blood cells
Taking blood out of your veins (300-500ml)
Low dose aspirin (Paxil)
Medication to decrease blood cells
Therapy to reduce itching
Phlebotomy is the mainstay of treatment-Aim is to
reduce the hematocrit and keep it less than 45% to
48% Hydration to reduce blood viscosity

1. Asses for Pain descriptions, headache, extremities, joints.

Rationale: Results from hyperviscosity, circulatory insufficiency,
increases in uric acid.
2. Perform/Provide
A. Elevate extremity
Rationale: Relieves pain by relieving pressure on area.
B. Apply cold cloth to head, heat to joints, extremities.
Rationale: Relieves discomfort
C. Avoid excessive movement or manipulation during activities
Rationale: Prevents unnecessary pain
D. Relaxation techniques
Rationale: Provides distraction and reduces discomfort

Assymtomatic at first.
Increased blood volume and viscosity.
Hypertension leading to headaches, dizziness, and vision and
hearing disrptions.
Venous stasis causes plethora (a ruddy, red color of the face,
hands, feet and mucous membranes)
Severe painful itching of the fingers and toes.
Retinal and cerebral vessels are engorged.
Hypermetabolism develops, causing weight loss and night
sweats.
Mental status maybe altered.
Thrombosis and hemorrhage are potential complications.

Education about smoking cessation

Preventing of CV disease
Maintaining adequate hydration
Prevention of blood stasis
Instruct in s/sx of thrombosis
Assess for possible bleeding (GI most common)
Monitor Hct and cell counts

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Polycythemia (Polycythemia
Vera)

Leukemia

Medication
busulfan (Myleran)
hydroxyurea (Hydrea
melphalan (Alkeran)
Radio active phosphorous

is a group of chronic malignant disorders of white

blood cells and white blood cell precursors.
Usual ratio of RBC to WBC is reversed.
Characterized by replacement of bone marrow by
malignant immature WBCs, abnormal immature
circulating WBCs, and infiltration of these cells in the
liver, spleen, and lymph nodes throughout the body.

Leukemia

Leukemia

MAJOR TYPES
1. Acute lymphoblastic leukemia
Lymphoblast proliferation in bone marrow and
peripheral tissues crowd the growth of normal cells.
Malignant cells resemble immature lymphocytes
however, they do not mature or function effectively
to maintain immunity.
Common in children and young adults.

MAJOR TYPES
Acute lymphoblastic leukemia
(Manifestations)
Recurrent infections; bleeding; pallor, bone pain,
weight loss, sore throat, fatigue, night sweats,
weakness.

Leukemia

Leukemia

MAJOR TYPES
2. Chronic lymphoblastic leukemia
Characterized by proliferation of small, abnormal,
mature lymphocytes in the bone marrow, peripheral
blood, and body tissues.
The abnormal cells are usually B lymphocytes that
are unable to produce adequate antibodies to
maintain normal immue function.
Primarily affects older adults; insidious onset and
slow, chronic course.

MAJOR TYPES
2. Chronic lymphoblastic leukemia
(Manifestations)
Fatigue; exercise intolerance; lymphadenopathy and
splenomegaly; recurrent infections, pallor, edema,
thrombophlebitis

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Leukemia

Leukemia

MAJOR TYPES
3. Acute myeloid leukemia
Characterized by uncontrolled proliferation of
myeloblasts (the precursors of granulocytes) and
hyperplasia of the bone marrow and spleen.
Common in older adults may affect children and
young adults.
Strongly associated with toxins, genetic disorders,
and treatment of other cancers.

MAJOR TYPES
3. Acute myeloid leukemia
(Manifestations)
Fatigue, weakness, fever; anemia; headache; bone
and joint pain; abnormal bleeding and bruising;
recurrent infection; lymphadenopathy; splenomegaly,
and hepatomegaly

Leukemia

Leukemia

MAJOR TYPES
4. Chronic myeloid leukemia
Characterized by abnormal proliferation of all bone
marrow elements.
Primarily affects adults; early course slow and stable,
progressing to aggressive phase in 3-4 years.

MAJOR TYPES
4. Chronic myeloid leukemia
(Manifestations)
Early: weakness, fatigue, dyspnea on exertion;
possible splenomegaly.
Later: Fever, weight loss, night sweats.

Leukemia

Leukemia

Treatment
1. ALL Chemotherapy; BMT or Stem Cell Transplant
2. CLL Often requires no treatment; BMY
3. AML Chemotherapy, SCT
4. CML Interferon Alpha; chemotherapy with imatinib
mesylate (Gleevec), SCT

Independent Interventions (ALL)

1. Assess client for symptoms of ALL, do thorough physical
examination to distinguish the symptoms from flu symptoms to
not mistaken the disease.
2. Client experiencing weakness and joint pains, instruct patient
to do non strenuous activities, provide patient a safe
environment, and decrease amount of external and internal
stressors. Keep patient safe and keep side rails up. Assist client
in ambulating if client is too weak. Inform watcher to assist in
daily activities that may cause stress and contribute weakness
and body ache.
3. In client with fever, monitor temp and perform tepid sponge
bath till fever subsides.

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Leukemia

Leukemia

Independent Interventions (ALL)

Dependent Interventions (ALL)

4. Client may experience anemia, therefore instruct patient to

eat more green leafy vegetables if able to, inform client/family of
diet including increase in iron, folate and vit b12
5. Patient might experience SOB, therefore watch for signs of
SOB, provide O2 if needed.
6. Lump around lymph nodes will occur, so therefore assure
client/ family that occurrence of it in the disease is normal,
inform not to promote any heat on the lump incase it may
aggravate.
7. Provide counseling and let client/ family to express feelings
and concerns. Provide emotional support
and encourage patient have patience with the treatments.

1. Assist in administration of anti- cancer drugs to client as

prescribed by the physician
2. Assist the physician in care of the treatment such as
chemotherapy, etc.
3. Promote group counseling or visitation with counsellors, work
hand In hand with the counsellor to
promote coping with the disease.
4. Provide health teaching on the disease and care if instructed
by phyisician, however oftenly done by
physicians. Provide feedback on progress of treatments.

Leukemia

Leukemia

Independent Interventions (CLL)

Independent Interventions (CLL)

1. Asses symptoms though early symptoms may not be visible.

2. For enlarged lymph nodes, inform patient about the cause
and to not promote heat.
3. Provide safe environment and promote rest, non strenuous
activities.
4. Pain may occur due to splenomegaly, teach deep breathing
exercises, splinting if possible.
5. Client with night sweats, give sponge bath with slightly cold
water to prevent clogging of dirt on skin
pores

6. Client might be aneroxic, watch for nausea and vomiting,

provide ice chips if needed, provide small frequent meals.
Encourage clients to eat healthiear and veggie content foods due
to anemic condition.
7. Watch for possible infections, if there is wound or cut, provide
aseptic care toprevent infection.
Patient may frequently get sick due to low immune, provide care
and promote rest and sleep with
proper intake of fluids.

Leukemia

Malignant Lymphoma

Dependent Interventions (CLL)

Lymphomas are malignancies of lymphoid

tissue.
They are characterized by the proliferation
of lymphocytes, histiocytes (resident
monocytes or macrophages), and their
precursors or derivaties.

1. Assist in administration of anti- cancer drugs to client as

prescribed by the physician
2. Assist the physician in care of the treatment such as
chemotherapy, etc.
3. Promote group counseling, support group or visitation with
counsellors, work hand In hand with the counsellor to promote
coping with the disease.
4. Provide health teaching on the disease and care if instructed
by phyisician, however oftenly done by
physicians. Provide feedback on progress of treatments.

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Malignant Lymphoma

Malignant Lymphoma

Pathophysiology (Hodgkins Disease)

Exact cause is unknown but believed to be
caused by Epstein-Barr virus (EBV) infection
and genetic factors.
Hodgkins disease develops in a single lymph
node or chain of nodes, spreading to adjoining
nodes.
Involved lymph nodes contain Reed-Sternberg
cells (malignant cells) surrounded by host
inflammatory cells.

Pathophysiology (Non-Hodgkins Disease)

Exact cause is unknown but believed to be
caused by Epstein-Barr virus (EBV) infection
and genetic factors.
It is a diverse group of lymphoid tissue
malignancies that do not contain ReedSternberg cells.
Tends to arise in peripheral lymph nodes and
spread early to tissues throughout the body.

Malignant Lymphoma

Malignant Lymphoma

FEATURES AND MANIFESTATIONS OF HODGKINS DISEASE AND NON

HODGKINS LYMPHOMA
FEATURE OR
MANIFESTATION

HODGKINS DISEASE

NON-HODGKINS
LYMPHOMA

Lymphadenopathy

Localized to a single node

or chain, often cervical,
subclavicular or
mediastinal

Multiple peripheral nodes,

nodes of the mesentery
often involved.

Spread

Orderly and continuous

Diffuse and unpredictable

Extranodal involvement

Rare

Early and common

Bone marrow involvement

Uncommon

Common

Fever, night sweats, weight

loss

Common

Uncommon until disease is

extensive

Other manifestations

Fatigue, pruritis,
splenomegaly; anemia,
neutrophilia

Abdominal pain, nausea,

vomiting; dyspnea, cough;
CNS symptoms,
lymphocytophenia

Treatment
Level of aggressiveness, stage at diagnosis,
and other medical problems that may exists.
Among the treatment options:
Chemotherapy,
Radiation therapy
Immunotherapy
Stem cell transplant

Malignant Lymphoma

Malignant Lymphoma

Dependent Nursing Interventions

Independent Nursing Interventions

Administer pain medications as ordered

Provide a well balanced, high calorie, high protein diet.
If the patient can't tolerate oral feeding, administer I.V
fluids.
Monitor the effectiveness of administered analgesics and
other medications.
Monitor the patients CBC, uric acid level, and serum
calcium level for abnormalities.
Make sure the patient receives through explanations
about all treatment.

Provide rest periods if the patient tires easily

Offer the patient such fluids as orange juice or ginger
ale to counteract nausea
Listen to the patient fears and concerns.
Involve the patient and his family in his care
whenever possible.
Provide the patient with plenty of fluids to help flush
out the cells that are destroyed during treatment.

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Multiple Myeloma

Multiple Myeloma

It is a malignancy in which plasma cells multiply

uncontrollably and infiltrate the bone marrow, lymph
nodes, spleen, and other tissues.
Plasma cells are B-cell lymphocytes that develop to
produce antibodies (immunoglobulins).

Pathophysiology

Multiple Myeloma

Multiple Myeloma

Diagnosis

Treatment
Stem cell transplantation
Combination of Chinese and Western medicine
Chemotherapy
Radiotherapy

Xrays

Bone marrow examination

CBC
Protein electrophoresis
S. Calcium, creatinine, uric acid and BUN levels are
elevated.
Urinalysis shows Bence Jone protein in uirine
Biopsy of myeloma

Malignant plasma cells arise from one clone (monoclonal)

of B cells that produce abnormally large amounts of a
particular immunoglobulin called the M protein.
This abnormal protein interferes with normal antibody
production and impairs the humoral immune response.
Also increases viscosity of blood damaging kidney
tubules.
As myeloma cells proliferate they replace the bone
marrow and infiltrate the bone itself.

Multiple Myeloma

Multiple Myeloma

Medications
Bortezomib (Velcade)
Thalidomide (Thalomid)
Lenalidomide (Revlimid)
Corticosteroids

Interventions
Rest: patients can do appropriate activities, but never do
strenuous exercise, preventing falls and bruise.
Bedrest: in order to prevent pathologic fracture, patient
should sleep on the hard bed, so elastic bed should be
avoided to use.
Diet: food should be high in protein, rich in vitamins and
digestible. Patients with renal dysfunction should be given low
sodium, low protein diet, in order to reduce the burden on the
kidneys. If hyperuricemia and hypercalcemia occur, patients
should be encouraged to drink more water and daily urinary
volume should be maintained above 2000ml, so as to alleviate
their clinical symptoms.

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Multiple Myeloma
Interventions
Mental guide: giving patients more love and care, helping
them face up to the reality, alleviating their anxieties,
encouraging them to face their conditions positively.
Support position with pillows. Bony prominences may be
painful due to infiltrate, pillows can help relieve pressure, thus
reducing pain. And for safety measures.
Determine position of greatest comfort, and assist as needed
into this position. the client is best able to identify positions
that minimize pain but may need assistant with repositioning.