A Case Study on

MULTIPLE MYELOMA

In Partial Fulfillment of the

Requirements in NCM 212 - RLE
CANCER ABERRATION/ IMMUNOLOGY ROTATION

Submitted to:
MARIE VANESSA GAMBET, RN
Clinical Instructor

Submitted by:
GABRIEL GUERERO, ST. N
KAYE MARNELLE JACOSALEM, ST. N
HAZEL JOYCE OBZUNAR, ST. N
BSN 3J – Group 2

October 9, 2020
Table of Contents

I. INTRODUCTION.......................................................................................................... 3

II. GOALS AND OBJECTIVES........................................................................................5

III. PATHOPHYSIOLOGY................................................................................................6

A. Etiology.................................................................................................................... 6

B. Symptomatology......................................................................................................7

C. Disease Process: Schematic Tracing....................................................................10

IV. DIAGNOSTICS/ LABORATORY CONFIRMATORY TEST......................................15

A. Diagnostic Tests....................................................................................................15

B. Nursing Diagnosis (NANDA)..................................................................................19

V. MANAGEMENT........................................................................................................ 20

A. Surgical.................................................................................................................. 20

B. Pharmacological/ Medical......................................................................................20

C. Nursing Intervention..............................................................................................23

VI. PROGNOSIS...........................................................................................................25

VII. DISCHARGE PLANNING.......................................................................................26

VIII. RELATED NURSING THEORY.............................................................................30

IX. REVIEW OF RELATED STUDIES...........................................................................32

X. REFERENCES......................................................................................................... 34
I. INTRODUCTION

Oncology nursing is defined as nursing which is concerned with the care of cancer patients
of all ages. This specialty seeks to reduce the risks, incidence, and burden of cancer by
encouraging healthy lifestyles, promoting early detection, and improving the management of
cancer symptoms and side effects throughout the disease trajectory. According to the Oncology
Nursing Society (2019), the primary role of an oncology nurse is to help people at risk for or
with a cancer diagnosis of cancer, coordinate care delivery, ensure safe delivery of cancer
treatments, help manage symptoms, optimize quality of life, support people with cancer and
their caregivers, advocate for the unique needs of people with cancer, and collaborate with the
interprofessional team to improve outcomes and reduce the impact of cancer on people,
families, communities, and populations.

Cancer is a group of diseases involving abnormal cell growth that has a potential to invade
or spread to other parts of the body. There are various types of cancer and one example of this
is multiple myeloma. Multiple myeloma is a hematologic cancer characterized by the
accumulation of malignant plasma cells in the bone marrow, which causes bone destruction,
blood abnormalities, and other potentially fatal complications (National Cancer Institute, 2016).
Globally, multiple myeloma affected 488,000 people and resulted in 101,100 deaths in 2015
(Cowan et al., 2018). This gives a five-year survival rate of about 49% (SEER, 2016).
Additionally, in a recent study conducted by the American Cancer Society (2020), revealed that
the new cases of multiple myeloma is estimated to be 32,270 and estimated deaths of 12, 830.

According to the Global Cancer Observatory (2019), multiple myeloma is ranked 23rd as
one of the most prevalent and deadly type of cancer in the Philippines. There were 708 number
of new cases and 624 deaths recorded in the year 2018. However, in a study conducted by
Alcantara et at., (2010), multiple myeloma is not part of the most occurring cancer types in
Davao City. There were also no evident number of cases of multiple myeloma found in Davao
City.

This case study comprises important learning points that can be applied to an actual
situation. By knowing the risk and factors contributing to the development of multiple myeloma,
the student nurses will be able to provide the right service to patients with the same condition in
the future and educate them on ways to manage the said disease. This case will serve as a
guide to student nurses and other members of the health care team to work on the

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improvement in implementing interventions, management, and services to the patients suffering
from this disease. Along with the knowledge this case study has shared to the future registered
nurses, the information acquired may also be a tool for comparison or as basis in future
researches to formulate ways in better nursing care.

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II. GOALS AND OBJECTIVES

General Objective
At the end of the three weeks of Cancer Aberration/ Immunology Rotation, the student nurses
will be able to apply their knowledge obtained from their Oncology Lecture, achieve
comprehensive learning in Multiple Myeloma, acquire skills in providing care for patients with
hematologic cancer and develop positive attitude for them.

Specific Objectives
The student nurses specifically aims to:
a. describe Multiple myeloma through a brief introduction;
b. formulate specific, measurable, attainable, realistic, and time-bounded
objectives;
c. identify clinical manifestations of Multiple myeloma;
d. present the pathophysiology of Multiple myeloma including its schematic and
narrative explanation
e. identify the ideal and possible diagnostic tests;
f. determine the management for Multiple myeloma including medical/surgical
procedures and nursing interventions;
g. justify the prognosis of the Multiple Myeloma if treated or not;
h. outline appropriate health teachings for discharge planning;
i. relate two nursing theories significant to the case;
j. impart three evidenced-based articles related to the disease;
k. formulate nursing care plans; and
l. list the references used in the comprehensive case analysis.

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III. PATHOPHYSIOLOGY

A. Etiology
Predisposing Factors Rationale
Growing older increases the chance of developing
multiple myeloma. Most people with myeloma are
Age
diagnosed after age 65 and are rare in people
younger than 40 (National Cancer Institute, 2018).
The risk of multiple myeloma is highest among
Race African Americans and lowest among Asian and
Americans (National Cancer Institute, 2018).
According to the American Cancer Society (2018),
Sex men are slightly more likely to develop multiple
myeloma than women.
Having a sibling or a parent who had multiple
myeloma may increase the likelihood of developing
the disease as much as four times when compared
Family history
to people who have no family history of multiple
myeloma (Cancer Treatment Centers of America,
2020).

Precipitating Factors Rationale

According to Shah (2020), there is a significant risk
of developing MM in individuals with significant
occupational exposures in the agriculture, food, and
Occupational exposure to petrochemical industries. An increased risk has
chemicals been reported in farmers, especially in those who
use herbicides and insecticides (eg, chlordane),
and in people exposed to benzene and other
organic solvents.
According to the Human Health Research Studies
Occupational exposure to
(2010), people exposed to ionizing radiation
ionizing radiation
increases the risk of developing multiple myeloma.
Stress Stress can be a very destructive force when it
comes to myeloma. Stress really disrupts the
immune system and myeloma is a cancer of the

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 immune system. In addition, the stress hormone
noradrenaline (the "flight" hormone, versus
adrenaline, the "fight" hormone) can actually trigger
cancer cell growth directly (International Myeloma
Foundation, 2012).
According to the American Cancer Society (2018),
Obesity being overweight or obese increases a person’s
risk of developing myeloma.
MGUS is a condition in which abnormal plasma
Monoclonal gammopathy of cells make a low level of M proteins. MGUS is a
undetermined significance benign condition, but it increases the risk of certain
(MGUS) cancer, including multiple myeloma (National
Cancer Institute, 2018).

B. Symptomatology
Signs and Symptoms Rationale
Anemia According to the International Myeloma Foundation
(2019), anemia is often the first symptom of
multiple myeloma. At least 60%-70% of patients
with multiple myeloma have anemia at the time
they are diagnosed. Myeloma cells interfere with
the blood-cell-making activities of the bone
marrow, often leading to a shortage of red blood
cells (RBCs), or anemia. This can also occur as a
side effect of myeloma treatment.
Bone Pain According to American Society of Clinical Oncology
(2020), bone pain is a common symptom. Myeloma
cells grow in the bone marrow and cortical bone,
causing local bone damage or generalized thinning
of the bone, which is called osteoporosis. This
makes the bone more likely to break. The back or
ribs are the most common sites of bone pain, but
any bone can be affected.
Osteolytic Lesions According to the International Myeloma Foundation
(2019), multiple myeloma disease can cause the

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 bones to become thinner and weaker and can
make holes appear in the bone (osteolytic lesions).
Osteolytic lesions are areas where bone has been
destroyed, leaving a hole in the bone. These
lesions in the spine are common, and when
severe, can lead to one or more vertebral
compression fractures, which can be painful and
even disabling.
Hypercalcemia According to National Health Service (2018), high
level of calcium in the blood (hypercalcaemia) can
develop in people with multiple myeloma because
too much calcium is released from affected bones
into the bloodstream.
Hyperviscosity syndrome Hyperviscosity syndrome (HVS) refers to the
clinical sequelae of increased blood viscosity.
Increased serum viscosity usually results from
increased circulating serum immunoglobulins and
can be seen in multiple myeloma (Hemingway,
2019).
Kidney impairment/ Kideney According to Faiman (2011), kidney dysfunction is
failure a common clinical feature of symptomatic multiple
myeloma. Patients with multiple myeloma who
have proteinuria may experience renal failure or
progress to end-stage renal disease.
Amyloidosis Kidney failure in patients with presumed multiple
myeloma may also result from amyloidosis.
Amyloidosis is a disease characterized by the
deposition of amyloid fibrils, which consist of
monoclonal light chains, in various tissues of the
body; it often leads to organ dysfunction. Amyloid
is a fibrillar structure that most commonly deposits
in the heart, kidneys, nervous system, or
gastrointestinal tract (Faiman, 2011).
Uremia Kidneys filter waste and extra fluid from blood, and
body gets rid of them through urine. If your kidneys

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 don’t work well due to its association to multiple
myeloma disease, those things can stay in your
blood. That condition is called uremia, or uremic
syndrome (Faiman, 2011).
Proteinuria According to Korbet and Schwartz (2006), renal
disease in myeloma most often presents as renal
insufficiency and proteinuria. Proteinuria is a
condition that occurs when there is a greater than
normal amount of protein in the urine.
Infection People with multiple myeloma are particularly
vulnerable to infection because the condition
interferes with the immune system, the body's
natural defence against infection and illness
(National Health Service, 2018).
Bleeding Some people with multiple myeloma have bruising
and unusual bleeding (haemorrhage) – such as
frequent nosebleeds, bleeding gums and heavy
periods. This is because the cancer cells in your
bone marrow can stop blood-clotting cells called
platelets from being made (National Health
Service, 2018).

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 Precipitating Factors
Predisposing Factors Occupational exposure to
Age (65) chemicals
Race (African) Occupational exposure to ionizing
Sex (men) radiation
Family History Etiology Stress

Page | 10
Obesity
Monoclonal gammopathy of
undetermined significance (MGUS)
DNA is damaged during the development of
stem cell into a B-cells
Development of malignant plasmablasts
Produce adhesive molecules and bind to Bone
Marrow Stromal Cells
C. Disease Process: Schematic Tracing

Malignant plasmablast grows into malignant

plasma cells (myeloma cells)
Uncontrolled proliferation of malignant plasma
cell clones (myeloma cells)
Diagnosis
Complete Blood Count
Blood chemistry
Urinalysis
Electrophoresis
Radiography
Biopsy (Bone marrow aspiration/
Bone marrow biopsy)
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rte Multiple myeloma is a cancer of plasma cells in which monoclonal malignant plasma cells
bro
proliferate in bone marrow. The risks of developing multiple myeloma are older adults aged 65
pla
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Nuyears old and above, highest risk of MM are also observed in racial groups of African
rsiAmericans, heredity or those with familial history of multiple myeloma and sex in which men are
ng:
more likely than women to develop the disease. Aside from those factors, people with recurrent
Pai
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stress, obesity and occupational exposure to radiation or chemical are also at risk in developing
namultiple myeloma. The one major factor that can contribute to the progression of multiple
ge
memyeloma is monoclonal gammopathy of undetermined significance (MGUS).
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Ac The disease process starts when the DNA is damaged during the development of stem cell
tivi
tyinto a b-cells. When b-cells is damaged, this gives rise to too many abnormal plasma cells.
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Abnormal plasma cells, which then become known as myeloma cells, divide, and expand within
stri
ctithe bone marrow causes development of malignant plasmablasts. Malignant plasmablasts will
on
s produce adhesive molecules which and bind to Bone Marrow Stromal Cells. Eventually,
Hemalignant plasmablast will grow into malignant plasma cells. And as a result, there will be
alt
h uncontrolled proliferation of malignant plasma cell clones.
Ed
uc When there is abnormal production of myeloma cells a formation of plasmacytomas will
ati
onresult. There will be compression of surrounding bone tissue, bone marrow and nerve endings
Re
which can lead to destruction of bone cell marrow and causes pain to patient. When there is
nal
Fudestruction of bone cell marrow, it will decrease osteoblast which is a bone forming cell and
nct
decreases bone deposition resulting to pathologic fracture. The destruction of bone cell marrow
ion
M
will also decrease hematopoiesis resulting to low RBC, platelets, and WBC. Leading to Anemia,
oni
torThrombocytopenia resulting to bleeding, and leukopenia resulting to increase susceptibility to
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any infections like pneumonia.
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ion Another thing that plasmacytoma cause is the release of IL-6 and Tumor Necrosis Factor
Pre
ve(TNF) which recruits and activates the osteoclast (cell that functions in the breakdown and
nti
onresorption of bone tissue). When it is attached to the bone tissue it produces acid and enzymes
Methat are capable of removing the inorganic calcium and phosphorus from the bone tissue. They
asu
can also break down organic material, such a collagen, that constitutes the bone itself. Initially,
res
the bone is broken apart with minerals still inside of the tissue and forms osteolytic lesions and
causes hypercalcemia as calcium are being released in the bloodstream. Therefore, there is a
continuous bone destruction that may cause pathologic fracture which will add up to the pain.

Page | 13
 Another result of proliferation of myeloma cells is the hyperproduction of monoclonal
components (serum monoclonal antibodies and monoclonal globulin protein). An increase in
serum monoclonal antibodies which binds to paraproteins will result in hyperviscosity
syndrome. This refers to any state in which there is increased viscosity of the blood. If HVS is
left untreated, congestive heart failure, ischemic acute tubular necrosis, and pulmonary edema
might happen that will result to death. An Increase in monoclonal globulin protein production will
start to accumulate in kidney tubules which will result in blockage. Leading to kidney impairment
or kidney failure. Due to the decrease in filtration capabilities of kidney, proteinuria, uremia, and
amyloidosis can happen. If this will be left untreated, this will also cause death.

For most types of cancer like multiple myeloma, a biopsy is the only sure way to diagnose.
Bone marrow biopsy and bone marrow aspiration are often done in this type of cancer.
Although, there are other diagnostic tests that may be used to diagnose multiple myeloma.
Complete blood count, blood chemistry, urinalysis, electrophoresis, and radiography are some
of the tests that are used to support diagnosis of multiple myeloma.

In this type of cancer, the abnormal plasma cells (myeloma cells) collect in one location
and form a tumor, called plasmacytoma. The primary aim of management for multiple myeloma
is to eliminate the plasmacytomas, destroying abnormal plasma cells, preventing or relieving
symptoms and complications, managing pain and slowing progression of the disease. The
treatment that is commonly used is radiotherapy. This involve focusing radiation on the
plasmacytoma to kill the malignant cells. The treatment is also generally given with
chemotherapeutic drugs like melphalan, cyclophosphamide and vincristine. Chemotherapy
slows down the progression of multiple myeloma by killing the abnormal plasma cells as well as
the normal cells. Chemotherapeutic drugs are also taken with bisphosphonates. This is used to
help reduce vertebral fractures and pain. Surgical managements like bone marrow transplant or
stem cell transplantation, kyphoplasty and vertebroplasty are also utilized to treat multiple
myeloma. However, multiple myeloma still remains incurable despite recent remarkable
advances in therapy resulting to poor prognosis from the disease. And if multiple myeloma and
its associated complications are left untreated, it could eventually lead to death.

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IV. DIAGNOSTICS/ LABORATORY CONFIRMATORY TEST

A. Diagnostic Tests

 Blood Tests
A test that measures the levels of red blood cells,
Complete Blood Count (CBC)
white blood cells, and platelets in the blood. If
there are too many myeloma cells in the bone
marrow, some of these blood cell levels can be
low. The most common finding is a low red blood
cell count (Anemia).

Blood Chemistry Test:

BUN and creatinine (Cr) levels show how well
Blood Urea Nitrogen (BUN) and Levels of
your kidneys are working. Higher levels mean that
Creatinine,
kidney function is impaired

Albumin,
A protein found in the blood. Low levels can be a
sign of more advanced myeloma. May be higher
in people with advanced myeloma. High calcium

Calcium, levels (Hypercalcemia) can cause severe

symptoms of fatigue, weakness, and confusion.

A test to measure the total amount of

Serum Protein Electrophoresis (SPEP)
immunoglobulin in the blood and find any
abnormal immunoglobulin.

This test measures the blood levels of the

Quantitative Immunoglobulins
different antibodies. The levels of these
immunoglobulins are measured to see if any are
abnormally high or low. In multiple myeloma, one
type of immunoglobulin has overgrowth that
crowds out the other types of immunoglobulins,
which is why patients may be susceptible to
certain kinds of infections, like pneumonia.

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 Immunofixation/ Immunoelectrophoresis This is used to determine the exact type of
antibody that is abnormal (IgG or some other
(IFE)
type).

A test that measures the amount of light chains in

Free light chains (FLC)
the blood. This is most helpful in the rare cases of
myeloma in which no M protein is found by SPEP.
Since the SPEP measures the levels of intact
(whole) immunoglobulins, it cannot measure the
amount of light chains.

Another protein produced by the malignant cells.

Beta2-Microglobulin (B2-M)
Although this protein itself doesn’t cause
problems, it can be a useful indicator of a
patient’s prognosis (outlook). High levels indicate
more aggressive disease.

 Urine Tests
A common test that looks at a sample of the urine
Urinalysis
to check how well the kidneys are working and tell
further if there is a kidney damage.

This test measures the amount of protein present

Urine Protein Level
in the urine. Compared with normal plasma cells,
myeloma cells produce too many immunoglobulin
proteins.

This is used for finding a monoclonal

Urine Protein Electrophoresis (UPEP)
immunoglobulin in urine

 Biopsy
In this procedure, the back of the pelvic bone is
Bone Marrow Biopsy
numbed with local anesthetic. A needle is inserted
into the bone and a syringe is used to remove a
small amount of liquid bone marrow. This causes
a brief, sharp pain. Then for the biopsy, a needle
is used to remove a tiny sliver of bone and
marrow, about 1/16-inch across and 1-inch long.
There is some soreness in the biopsy area when
the numbing medicine wears off. Most patients go

Page | 16
 home immediately after the procedure. A doctor
will use a microscope to look at the bone marrow
tissue to see the appearance, size, and shape of
the cells, how the cells are arranged and to
determine if there are myeloma cells in the bone
marrow and, if so, how many.

If an imaging study shows a potential tumor or

Fine Needle Aspiration (FNA)
other abnormality, an additional aspiration during
the bone marrow biopsy can be performed. This
test uses a very thin needle and an ordinary
syringe to withdraw a small amount of tissue from
a tumor
This test is similar to FNA but a larger needle is
Core Needle Biopsy (CNB)
used and a larger tissue sample is removed.

In this test, a part of the biopsy sample is treated

Immunohistochemistry
with special antibodies (man-made versions of
immune system proteins) that attach only to
specific molecules on the cell surface. These
antibodies cause color changes, which can be
seen under a microscope. This test may be
helpful in telling different types of cells apart and
in finding myeloma cells.

For this test, a sample of cells is treated with

Flow Cytometry
special antibodies that stick to the cells only if
certain substances are present on their surfaces.
The cells are then passed in front of a laser
beam. If the cells now have antibodies attached to
them, the laser will cause them to give off light,
which can be measured and analyzed by a
computer. Groups of cells can be separated and
counted by these methods. It helps determine if
the cells are abnormal, myeloma, another type of
cancer, or a non-cancerous disease.

A test that evaluates chromosomes (long strands

Cytogenetic Analysis (Karyotyping)
of DNA) in normal bone marrow cells and
myeloma cells. Some myeloma cells may have

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 too many chromosomes, too few chromosomes,
or other chromosome abnormalities (such as
translocations and deletions). Finding these
changes can sometimes help in to predicting a
person’s prognosis (outlook). Cytogenetic testing
usually takes about 2 to 3 weeks to get a result.

This test uses special fluorescent dyes that only

Fluorescence in situ Hybrizisation (FISH)
attach to specific parts of chromosomes. It can
find most chromosome changes (such as
translocations and deletions) that can be seen in
the lab in standard cytogenetic tests, as well as
some changes too small to be seen with usual
cytogenetic testing. It’s very accurate and results
are often available within a couple of days.

 Imaging Test
Bone destruction caused by myeloma cells can be
Bone X-rays
detected with x-rays. This is called a bone survey or
skeletal survey.

This produces detailed cross-sectional images of your

Computed Tomography (CAT Scan)
body. Instead of taking one picture, like a conventional
x-ray, a CT scanner takes many pictures of the part of
the body being studied as it rotates. Sometimes, this
test can determine if bones have been damaged by
myeloma. It can also be used to guide a biopsy needle
into an area of concern.

It use radio waves and strong magnets instead of x-

Magnetic Resonance Imaging (MRI)
rays. The energy from the radio waves is absorbed and
then released in a pattern formed by the type of tissue
and by certain diseases. A computer translates the
pattern of radio waves given off by the tissues into a
very detailed image of parts of the body. It can also be
used to look at the bone marrow in patients with
multiple myeloma.

With a PET scan, radioactive glucose (sugar) is

Positron Emission Tomography (PET Scan)
injected into the patient’s vein to look for cancer cells.

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 Because cancers use glucose (sugar) at a higher rate
than normal tissues, the radioactivity will tend to
concentrate in the cancer. A scanner is used to spot
radioactive deposits.

B. Nursing Diagnosis (NANDA)

1. Chronic pain related to osteoclast activities as evidenced by presence of lytic lesions in
pelvis
2. Activity intolerance related to
3. Risk for infection related to altered immunological function
4. Risk for pathological facture related to decrease bone mass
5. Fluid deficit related to hypercalcemia as evidenced by Bence Jones proteinuria
6. Anxiety related to diagnosis of hematological cancer

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V. MANAGEMENT

The treatment highly depends on the manifestation of symptoms and the patient’s overall
health. Overall goals are to eliminate myeloma cells, control tumor growth, control pain, and
allow patients to have an active life. While there is no cure for multiple myeloma, the cancer can
be managed successfully in many patients for years.

A. Surgical

1. Bone Marrow Transplantation/Stem Cell Transplantation

The bone marrow that contains cancer is replaced by highly specialized cells, called
hematopoietic stem cells, that develop into healthy red blood cells, white blood cells, and
platelets in the bone marrow. There are 2 types of stem cell transplantation depending on the
source of the replacement blood stem cells: allogeneic (ALLO) and autologous (AUTO). ALLO
uses donated stem cells, while AUTO uses the patient’s own stem cells. For multiple myeloma,
AUTO is more commonly used. In both types, the goal is to destroy all of the cancer cells in the
marrow, blood, and other parts of the body using high doses of chemotherapy and then allow
replacement blood stem cells to create healthy bone marrow and better immunity.

B. Pharmacological/ Medical

1. Chemotherapy

A chemotherapy regimen (schedule) is the use of drugs to destroy cancer cells, usually by
keeping the cancer cells from growing, dividing, and making more cells, and usually consists of
a specific number of cycles given over a set period of time.

 cyclophosphamide (Cytoxan, Neosar)

 doxorubicin (Adriamycin, Rubex)
 melphalan (Alkeran, Evomela)
 etoposide (VePesid, Etopophos, Toposar)

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  cisplatin (Platinol)
 carmustine (BiCNU, Gliadel)
 bendeka (Belrapzo, Bendeka, Treanda)

The side effects of chemotherapy depend on the individual and the dose used, but they can
include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhea or
constipation. Other side effects include peripheral neuropathy (tingling or numbness in feet or
hands), blood clotting problems, and low blood counts. These side effects usually go away once
treatment is finished. Occasionally an allergic reaction such as skin rash may occur and the
drug may have to be stopped.

2. Targeted Therapy

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the
tissue environment that contributes to cancer growth and survival. This type of treatment blocks
the growth and spread of cancer cells and limits damage to healthy cells. In recent years,
targeted treatment, sometimes called novel therapy, has proven to be increasingly successful at
controlling myeloma and improving prognosis.

 Proteasome inhibitors. bortezomib (Velcade), carfilzomib (Kyprolis), and ixazomib

(Ninlaro) are classified as proteasome inhibitors. They target specific enzymes called
proteasomes that digest proteins in the cells. Because myeloma cells produce a lot of
proteins, they are particularly vulnerable to this type of drug. Bortezomib is approved to
treat newly diagnosed patients. The drug also treats recurrent myeloma, as do
carfilzomib and ixazomib.
 Histone deacetylase inhibitors. panobinostat (Farydak), an inhibitor of the enzyme
histone deacetylase (HDAC), also treats recurrent myeloma. HDACs help keep the DNA
tightly coiled, while panobinostat helps uncoil the DNA and activate genes that stop or
slow the growth of cancer cells.
 Monoclonal antibodies. elotuzumab (Empliciti) and daratumumab (Darzalex) are
monoclonal antibodies that bind to myeloma cells and label them for removal by the
person's own immune system. A drug combination of daratumumab and hyaluronidase-
fihj (Darzalex Faspro) may also be used to treat multiple myeloma. This combination is
given under the skin of the abdomen and is quicker than when it is given by injection
through a vein.

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  Nuclear export inhibitors. Selinexor (Xpovio) is a targeted therapy that is given in
combination with dexamethasone, a steroid available as a generic drug. This
combination is used to treat adults with multiple myeloma that has come back after at
least 4 previous treatments.

Targeted therapies may also be used in combination with chemotherapy,

immunomodulatory drugs, or steroid medications (see below), because certain combinations of
drugs can sometimes have a better effect than a single drug. For example, the drugs
lenalidomide, bortezomib, and dexamethasone, as well as bortezomib, cyclophosphamide, and
dexamethasone, are offered in combination as initial treatment. Clinical trials are exploring
whether the combination of lenalidomide, bortezomib, and dexamethasone may be as effective
as lenalidomide, bortezomib, and dexamethasone followed by bone marrow/stem cell transplant

3. Immunotherapy/ Biologic Therapy

It is designed to boost the body's natural defenses to fight the cancer. It uses materials
made either by the body or in a laboratory to improve, target, or restore immune system
function. These drugs also keep new blood vessels from forming and feeding myeloma cells.
Thalidomide and lenalidomide are approved to treat newly diagnosed patients. Lenalidomide
and pomalidomide are also effective for treating recurrent myeloma.

 thialidomide (Thalomid)
 lenalidomide (Revlimid)
 pomalidomide (Pomalyst)

4. Corticosteroids

They regulate the immune system to control inflammation in the body. They are also active
against myeloma cells. lenalidomide and dexamethasone as induction and maintenance
therapy is recommended for those who are not able to have stem cell transplantation. Adding
bortezomib to this combination has recently been shown to be effective in a clinical trial.

 Prednisone (Rayos, Sterapred, Deltasone)

 Dexamethasone ( Decadron, Dexasone, Diodex, Hexadrol)

5. Bone-modifying drugs

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 These drugs help strengthen the bone and reduce bone pain and the risk of fractures.
There are 2 types of bone-modifying drugs available for treating bone loss from multiple
myeloma. The choice of drugs depends on your overall health and your individual risk of side
effects.

 Bisphosphonates. zoledronic acid (Zometa) and pamidronate (Aredia), block the cells
that dissolve bone, called osteoclasts. For multiple myeloma, either pamidronate or
zoledronic acid is given by IV every 3 to 4 weeks.
 Denosumab (Xgeva) is an osteoclast-targeted therapy called a RANK ligand inhibitor. It
is approved to treat multiple myeloma and may be a better option for people with severe
kidney problems. Denosumab is considerably more expensive than bisphosphonates. It
has been shown to have similar effectiveness to bisphosphonates.

6. Radiation Therapy

This treatment uses beams of energy, such as X-rays and protons, to damage myeloma
cells and stop their growth. Radiation therapy may be used to quickly shrink myeloma cells in a
specific area — for instance, when a collection of abnormal plasma cells form a tumor
(plasmacytoma) that's causing pain or destroying a bone.

C. Nursing Intervention

1. Pain management

The nurse should fully assess for the type of pain, what makes it better or worse, and
gathering subjective and objective data (PQRST). Administer pain relievers as ordered
(NSAIDs).

2. Prevention of infection

Pneumococcal infections are common in patients with multiple myeloma, especially during
the first 3 months of treatment; vaccination should be completed at the time of diagnosis to
minimize preventable illness. The use of prophylactic antibiotics soon after diagnosis shows
a trend of reducing infection risk.

3. Preventing pathological fracture/bone injury

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 Prompt recognition of the signs of spinal-cord compression. Advise to use alternative or
complementary treatment modalities such as braces and promote body mechanics

4. Administration of chemotherapy

The nurse may assist in the treatment phase of the disease by administering chemotherapy.
If the patient experiences adverse effects, the nurse should provide emotional and physical
support and contact the provider for orders as needed to assist with nausea, vomiting, or
pain.

5. Maintaining hydration

Hypercalcemia is managed with aggressive hydration with intravenous fluids. Highlight the
importance of hydration and encourage patients to drink enough fluid to produce three liters
of urine daily if there is an excess of light chain proteins in the urine (called "Bence Jones
proteinuria")

6. Patient and family education

This includes psychosocial support of the patient and family; and provision of relevant, high-
quality, and up-to-date information at all stages of their disease. It is critical that the nurse
provides education and written materials to the patient about monitoring for signs of
infection and what symptoms should prompt the patient or family to call or return to the
healthcare facility.

7. Assist in specimen collection

One of the many responsibilities assigned to nurses, is to collect and label specimen for
analysis and to ensure their delivery to the lab. And knowing the proper way of gathering
specimen is necessary for self-protection and to prevent the spread of disease.

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VI. PROGNOSIS

There is no cure for multiple myeloma. Due to the increasing older population, more
patients are seeking treatment to this disease. There are some treatment options considered by
medical professionals that can only prolong remissions rather than provide a cure. However,
unavailability of treatments is possible to most because of age limitations. For many patients if
treated earlier have the possibility to control the illness and maintain their level of functioning
quiet well for extended years.

According to Davis (2019), ongoing research focuses in this disease that may prevent
progression to a more active state. With the help of advancements and scientifically base
knowledge, today’s treatments and therapies are less toxic and more effective than before. The
prognosis for myeloma is variable and fair. Survival rate is about three years, but some patients
have a life expectancy of 10 years. The American Cancer Society (ACS) stated that survival
rate multiple myeloma patient depending on the approximate stage and response to therapy as
follows; stage I: early disease with little anemia, relatively small amount of M protein and no
bone damage, survival rate of 62 months; stage II: more anemia and M protein as well as bone
damage, 44 months; stage III: still more M protein, anemia, as well as signs of kidney damage,
29 months.

Unfortunately, life expectancy if the disease worsens averages about nine months. If left
untreated and early onset of symptoms are ignored death may occur. This is a serious case
that needs sufficient health teachings by student nurses, close monitoring of trained nurses and
medical personnel will likely be important in the treatment team.

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VII. DISCHARGE PLANNING

MEDICATION/ TREATMENT

 Advised to give the prescribed medications at the right time, right dose, right frequency
and right route
 Advised patient and the family to take the entire course of prescribed medications.
Medications must be continued according to doctor’s instructions. Particularly,
dexamethasone (Decadron) often combined with other agents such as melphalan,
(Alkeran), cyclophosphamide (Cytoxan), doxorubicin (Adriamycin), vincristine (Oncovin)
and BCNU (Carmustine). With recent advancement new therapeutic option such as
sedative thalidomide (Thalomid), (Bare, Smeltzer, 2016).
 Emphasized the importance of taking the medication as prescribed. To treat pain,
prevent an infection, low blood counts caused by the cancer or its treatment, side
effects, such as nausea or constipation from other treatments, treat or slow bone
disease and help immune system fight cancer (Bare, Smeltzer, 2016).
 Close observation by the family on pain management for the patient. Adequate intake of
NSAIDs medication as prescribed by physician for mild pain.
 Keep appointments for all other testing you may need. Testing may include: Blood tests,
Bone X-rays, Chest X-ray
 Talk with the physician about any questions or fears a patient have.
 Outpatient Department (OPD) follow-up specially on medication regarding
Chemotherapy and Radiation treatment
 Refer to the healthcare provider if the patient has new or worsening symptoms: Back
pain, depression, frequent infections. If the patient had surgery, signs of infection around
surgical wound should be monitored by the family members. It includes: wound area is
more red or painful, warm to touch, have blood, pus, or other fluid coming out from the
would site, fever, chills or muscle aches (Bare, Smeltzer, 2016).

Rationale: To ensure safe drug administration, nurses are encouraged to follow the five rights
('R's; patient, drug, route, time and dose) of medication administration to prevent errors in
administration. To avoid harm or injury among patient. Failed to follow these rights can lead to a
permanent disability or a fatality. Proper treatment at home upon discharge can decrease the

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chances of readmission to the hospital and can also help in fast recovery. Even though the
patient feels better, it’s important to have the doctor monitor her progress

EXERCISE

 Encouraged patient to take deep breathing exercises to facilitate circulation.

 Regular, light exercise may decrease fatigue and facilitate coping at least 150 minutes
of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise (e.g. walking,
jogging, cycling, swimming) each week
 Many people lose muscle, but gain fat, through cancer treatment. Two to three
resistance exercise (e.g., lifting weights) sessions each week targeting the major muscle
groups
 Flexibility exercises (stretching). Stretching is important to keep moving, to maintain
mobility
 Referral to an accredited exercise physiologist and/or physical therapist with experience
in cancer care

Rationale: Exercises are to help individuals to improve body function and to promote the client’s
optimal level of well-being. Lack of physical and “too much rest” can actually contribute to
deconditioning and associated fatigue. By selecting appropriate and individualized
interventions, ways to conserve energy are developed to help the patient plan daily activities.

HYGIENE/ ENVIRONMENT

 If the patient had surgery, advice the family to care of surgical wound: Keep the surgical
wound clean (Berman, et al., 2016).
 hand washing specially to change the dressing on the patient’s surgical wound, wash
hands before changing the dressing and after disposing of the dressing (Berman, et al.,
2016).

Instruct the family to assist the patient in:

 taking bath regularly, to minimize skin dryness in older adults, avoid excessive use of
soap. Changes of aging includes fragile skin, less oil and moisture and a decrease in
elasticity. The ideal time to moisture the skin is immediately after bathing (Berman, et
al., 2016).

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  dress properly and neatly
 to do oral hygiene as decay of the tooth root is common among older adults

Advice the family to ensure appropriate lighting

 Remove unsafe objects

 Ensure uncluttered and clam environment
 Provide firm mattress to promote comfort and avoid sleep disturbances
 Good ventilation is important to remove unpleasant odors.

Rationale: The goals of home health care services is to help individuals to live with greater
independence and personal hygiene stop the spread of germs and illness. As older adults are
at risk for fall, burns and automobile crashes. Both patient and the family need to be aware of
what contributes a safe environment in home and community settings. Injuries are often caused
by human conduct and can be prevented.

DIET

 Maintain a healthy weight. Obesity may also increase the risk for cancer
 Avoid fatty foods, alcohol, salt-cured or smoked meats, foods containing nitrates such
as celery, lettuce, radishes, spinach and nitrites such as bacon, ham, corned beef and
hot dogs, and a high caloric dietary intake. These dietary substances associated the
increase risk among cancer patients (Bare, Smeltzer, 2016).
 Eat small, frequent meals throughout the day. It helps to minimize treatment-related side
effects such as nausea.
 Avoid foods with strong odors, spicy and fried. Instead, choose foods that are at room
temperature and bland such as crackers, cheese, canned fruit, yogurt, toast, potatoes,
rice, and pasta since medication of Multiple Myeloma often cause nausea and vomiting
(Bare, Smeltzer, 2016).
 Choose protein-rich foods. Lean meats such as chicken, fish, or turkey, eggs, low-fat
dairy products such as milk, yogurt, and cheese or dairy substitutes, nuts and nut
butters, beans and soy foods. Protein helps the body to repair cells and tissues. It also
aids in the recovery and maintenance of the immune system (Bare, Smeltzer, 2016).

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  Include whole grains. It provides a good source of carbohydrate and fiber, which help
sustain energy levels such as oatmeal, whole wheat breads, brown rice and whole grain
pastas (Bare, Smeltzer, 2016).
 Aim to eat a minimum of 5 servings of whole fruits and vegetables daily
 Stay hydrated. Aim to drink 8 glasses of water daily.
 Practice good food safety. To avoid further risk of infection

Rationale: With an adequate food and nutrition component for the client, it cannot add
complication for his/her recovery. Promoting health education helps to optimize patient’s
nutritional intake and engage in healthy eating behaviors.

SPIRITUAL/ SAFETY

 Advice the family to give moral support and widen their understanding
 Encourage the family to pray daily
 Advise the family to keep watch the patient at all times
 Avoid rushing the client with activities. Instruct the client to rise slowly from a lying to
sitting to standing position, and to stand in place for several seconds before walking
 Provide assistance with ambulation as needed. Use ambulatory devices as necessary
(cane, crutches, walker, braces, wheelchair), (Berman, et al., 2016).
 Provide nonslip footwear
 Avoid overexposure to the sun, wear protective clothing, and use a sunscreen to
prevent skin damage from ultraviolet rays (Berman, et al., 2016).

Rationale: It gives meaning and purpose to the patient’s life that by faith it may inspire them
with hope, seek resolution, transcend physical and conscious constraints. Consider patient
safety at home to reduce such adverse outcomes.

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VIII. RELATED NURSING THEORY

Philosophy and Science of Caring by Margaret Jean Watson

Jean Watson believes the practice of caring is central to nursing as she remarked “Caring
in nursing conveys physical acts, but embraces the mind-body-spirit as it reclaims the
embodied spirit as its focus of attention”. Multiple Myeloma is a malignant disease resulted to a
compromised immune system. Impaired bone marrow might affect secondary defenses inside
our body and would manifest various symptoms a patient can hardly to handle. The situation
depicts Watson’s theory that better care for the patient will be given. Establish a connection
which develop human caring relationship. It emphasized that the nurse must create healing
environment at all levels that focuses on 10 carative factors that are now been translated to 10
clinical caritas derived from a humanistic perspective with a scientific knowledge base, proper
assistance for the patient’s basic needs and encourage subtle environment of energy whereby
leading to wholeness and comfort between the patient and the nurse.

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 Adaptation Model by Sister Callista Roy

Sister Callista Roy defines adaptation as “the model provides a way of thinking about
people and their environment that is useful in any setting. It helps one prioritize care and
challenges the nurse to move the patient from survival to transformation”. This developmental
theory base on the essence of growth and maturation as a lively process of transformation. Life
is unique and go through multitude of different factors that makes a concept of caring special. In
general, a developmental stage a person experienced are different from the other. Student
nurse practicing health profession must learn and appreciate the changes that makes us
“human”. The goal of Roy’s model on patient diagnosed with Multiple Myeloma is to enhance
life process through four adaptive modes. It involves the body’s basic physiological needs.
Encourage the patient to participate in self-care activities and rehabilitation, interdependence
mode and role function involves support system with the family. A continuous warm
communication between family members might provide security and affection to the patient.
Self-concept mode to encourage patient verbalized his own feelings for the nurse to render new
coping strategies. Adaptive response contributes to health that supports the integrity of the
patient about the current situation and have coping interaction between the environment either
internal or external to achieve survival, growth and development.

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IX. REVIEW OF RELATED STUDIES

Important research into multiple myeloma is being done in university hospitals, medical
centers, and other institutions around the world to learn more about multiple myeloma, ways to
prevent it, how to best treat it, and how to provide the best care to people diagnosed with this
disease. Each year, scientists find out more about what causes the disease and how to improve
treatment. There are many new drugs being tested and evidenced-base managements are
evaluated.

Multiple myeloma complications including anemia, bone destruction and end-organ

damage can severely impacts health-related quality of life. Patients require symptomatic
treatment of these complications to prolong their remission and decreasing morbidity. According
to the study presented by Qureshi et al. (2020), multiple myeloma imposes multi-organ
complications that needs meticulous attention. With that, the study discussed different clinical
presentations and managements including renal insufficiency, easy fatigability, bone pain,
autologous stem cell/bone marrow transplantation and coagulopathy. It was also discussed
Bortezomib’s effectiveness and safety profile in Filipino patients with multiple myeloma. Thus,
the study concluded that bortezomib drug is likely to continue being an important part of the
clinical treatment and management of patients with myeloma. In an another study conducted by
Robak et al. (2018), showed that multiple myeloma is the second most common hematologic
malignancy in adults. As incidence of multiple myeloma has increased over the last decade,
several new drugs with different mechanisms of action are studied to approach patients with
relapse or refractory multiple myeloma. Hence, the study investigated the role of the cellular,
microenvironmental and molecular mechanism to know how it involves in drug resistance of
patients with multiple myeloma. It was revealed that the most common mechanisms of
resistance are during the conventional chemotherapy, such as treatment with vincristine and
doxorubicin since they are known to act through the expression of multidrug resistance gene
(MDR gene) and p-glycoprotein in multiple myeloma cells. However, the study also revealed
that there are more factors that could contribute to resistance to these drugs, including genetic
mutations, clonal evolution of multiple myeloma cells and changes in bone marrow
microenvironment. The genetic mutations and abnormalities are well known to play a central
role in multiple resistance to available drugs, and epigenetic aberrations mainly affecting the
patterns of DNA methylation and histone modifications of genes, especially tumor suppressors,

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can be involved in the resistance mechanism. In addition, drug resistance can also be
developed by the clonal evolution of multiple myeloma cells. Moreover, tumor microenvironment
in the bone marrow also contains important factors influencing disease progression and
resistance to therapy.

These discoveries about effective multiple myeloma treatments are helping researchers
develop new drugs to slow down the cancer, reduce complications and treat patients with
relapse or refractory multiple myeloma. However, prevention of disease is still better than
treatment for disease in any kind of health situation. In a recent study conducted by the
Washington University School of Medicine in St. Louis (2016), showed that weight loss may
help prevent multiple myeloma. The study found out 55 and 98 percent of overweight and
obese MGUS patients have higher risk and developed multiple myeloma compared to the 3.5
percent of people at normal weight that are affected by the disease. Further studies are able to
seek information concerning how weight change plays a huge role in the progression of MGUS
to multiple myeloma. Since extra weight is a modifiable factor, the study aims to encourage
different interventions strategies to prevent the condition. Therefore, close monitoring and
maintaining healthy lifestyle should be prioritized.

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