Lung Center of the Philippines

Quezon Avenue, Quezon City

General Nursing

A Case Study: Non-Hodgkin’s B Cell Lymphoma, Anemia of Chronic Origin, SIADH,

Severe Sepsis

Presented By:
(Covid ER – Emergency Room)

Jaqueline V. Dantes, RN
John Paul T. Dalayoan, RN
Kaylie Jamayca Marie L. Pasamonte, RN
Maricar F. Garcia, RN
Rommel C. Dugay
I- INTRODUCTION

Lymphomas represent one of the commonest malignancies. There has been an increase in
Non-Hodgkin Lymphoma (NHL) cases in past few decades and among B cell lymphomas
diffuse large B cell lymphoma (DLBCL) is the commonest type. Anemia is frequently
encountered in lymphoma patients and even observed before patients are started on
chemotherapy and in the absence of bone marrow involvement. It is a presenting feature in
approximately 40% of patients with Hodgkin’s Lymphoma (HL) and is considered an
important adverse prognostic factor for outcomes of therapy especially in the background of
bone marrow involvement which is yet another factor associated with poor prognosis.

Anemia is commonly encountered in cancer patients; however, this problem is greater

in lymphoma and multiple myeloma. In patients with lymphoma, anemia has been shown to
be an independent prognostic factor with worse outcome of therapy and increased mortality.
This can lead to feeling tired, lightheaded, or short of breath. Anemia that is causing symptoms
can be treated with red blood cell transfusions. Drugs that boost red blood cell production can
also be used, but these are linked to worse outcomes, and so are generally only used for people
who decline blood transfusions.

According to a report by European Cancer Anemia Survey (ECAS), 39% of lymphoma

patients were anemic at the time they were enrolled in the survey and only 47.3% of the anemic
patients received any treatment for anemia during this survey, emphasizing the need to identify
anemia at the time of diagnosis and adequately treating it in these patients. Similar prevalence
of anemia (42.4%) was found in a prospective study by Gosh et al from India, while other
studies of non-Hodgkin’s lymphoma reported their figures 32% and 35.3%. More lymphoma
patients were male (66.7%) as compared to only 33.33% females. Another study from Pakistan
also suggested that the prevalence of NHL was higher in males (69%) than in females (31%).
Although male population was higher in their study of NHL, but anemia was more frequent
in female patients. Higher prevalence of anemia in females has also been reported in other
similar studies, which likely reflects ongoing losses in young females in reproductive age
group.
 The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is caused by the
excessive release of antidiuretic hormone (ADH, also known as vasopressin) from the posterior
pituitary gland and can cause hyponatremia in hospitalized patients with an incidence as high
as 30%. SIADH is not difficult to diagnose in clinic. It can be secondary to a variety of
disorders, such as medications, malignancies, surgery, and HIV infection or be idiopathic.
While SCLC is the primary malignancy causing SIADH, lymphoma can also induce this
condition.

Several types of cancers cause excessive production of antidiuretic hormone (ADH)

leading to a condition called SIADH (syndrome of inappropriate ADH release). The major role
of ADH hormone is to retain water in the body, so when its production is increased, excessive
water retention dilutes salt concentration resulting in hyponatremia. ADH hormone production
can also be increased due to chemotherapy. Vincristine, Vinblastine, Ifosfamide, Cisplatin,
Melphalan and Cyclophosphamide are among the chemotherapeutic agents known to cause
SIADH and hyponatremia. Moreover, nausea and pain which are commonly seen in cancer
patients can stimulate ADH hormone production and lead to hyponatremia.

Sepsis when severe, can lead to septic shock and death. One reason is bacterial infections
which causes systemic reactions in the body also cause our immune system to release cytokines
to fight the infection. In a typical infection, the cytokines will dilate the blood vessels at the
site of the infection to allow more blood to pass through the area, carrying the cells and
mediators needed to fight the bacteria. However, in sepsis, the response involves the entire
body with inflammation essentially occurring everywhere.

With systemic response, all blood vessels dilate causing the blood pressure to drop. Instead
of assisting in fighting the infection, the body’s response to sepsis slows down blood flow
making immune system less effective. The bacteria can damage vital organs and lack of blood
flow can spark organ failure. Organ failure and low blood pressure are the two biggest dangers
for severe sepsis and septic shock, making it a fatal condition for up 40-50% of patients.
 II- DEMOGRAPHICS

Patient’s Profile

Name: L. L.

Diagnosis: Non-Hodgkin’s Lymphoma, Anemia in Chronic Disease

Age: 29

Gender: Female

Race: Filipino

Educational Attainment: High School Graduate

Occupation: Former sales lady

Geographical Area: Urban

Past Medical History

Ø The patient is a diagnose case of Non-Hodgkin’s with Primary Mediastinal B Cell

Lymphoma last January 2021.
Ø Undergone two lines of chemotherapy using Vincristine. The patient completed 5
cycles of line 1 chemotherapy last July 2021 at ambulatory oncology of LCP. Still for
completion of second line chemo, due for 3rd cycle. Both 1st cycle and 2nd cycle of line
2 chemotherapy was given as in patient at ward 3A of LCP. Last cycle of chemotherapy
was February 8, 2022. She was given Dexamethasone, Ondansetron and
Diphenhydramine IV as pre-medications.
Ø Patient L. L. was also treated with 4 sessions of radiotherapy. Although she is unable
to recall the specific dates the procedures were performed.
Ø Compliant to scheduled medical checkup and admitted having had several injections
of erythropoietin post chemo.
Ø No maintenance medication.
Ø No known allergies. No history of accident or trauma.
Present Medical History

Ø CHIEF COMPLAINT: Difficulty of breathing and low blood pressure.

Ø Arrived at Covid ER due to difficulty of breathing. Three weeks prior to ER consult,
patient experienced easy fatigability when doing normal activities of daily living but
able to sleep on supine position. Two weeks prior to ER consult, patient was mostly on
bed due to shortness of breath (SOB) and easy fatigability. One week prior to ER
consult, patient unable to sleep flat on bed. Mostly on high back rest position and still
with episodes of SOB and fatigue. Few hours prior to ER consult, persistent SHO is
experienced, and patient can only tolerate orthopneic position, hence consult was done.
Ø Initial Vital Signs:
BP- 84/53mmhg HR: 110bpm RR: 26cpm T- 36.2 O2 SAT- 98%
Ø Weight: 33kg Height: 155.44cm
Ø BMI: 13.7 (Underweight BMI)
- Healthy weight for the height: 44.7 kg – 60.1 kg.

Environmental History

Ø The patient is residing in an urban area.

Ø Water source for drinking is commercialized water and garbage are being collected.
Ø Previously worked as a sales lady at a department store but forced to resign when
underwent chemotherapy last 2021. Since then, patient stayed mostly at home.
Ø Known minimal exposure to air pollution.

Personal History

Ø The patient is perfectly compliant to her chemotherapy, radiotherapy treatments and

follow up checkups with her oncologist.
Ø Former smoker, 2.5 pack-years.
Ø Former occasional alcoholic drinker.
Ø No vaccine for Covid due to her current diseases requiring clearance form her
physician.
Physical Examination

Assessment Findings

INTEGUMENTARY

• Skin Pale skin

Poor skin turgor on both legs, (+) grade 3+

bilateral bipedal edema.

No skin lesions
Evenly distributed hair.
• Hair
With short, black and brittle hair.
Smooth and has intact epidermis
• Nails
With short and clean fingernails and toenails.
Convex and with capillary refill time of 3
seconds.
Rounded, normocephalic and symmetrical,
SKULL
smooth and has uniform consistency. Absence
of nodules or masses.
Symmetrical facial movement, palpebral
FACE
fissures equal in size, symmetric nasolabial
folds.

EYES AND VISION

Hair evenly distributed with skin intact.
• Eyebrows
Eyebrows are symmetrically aligned and have
equal movement.

Equally distributed and curled slightly

• Eyelashes
outward.
 Skin intact with no discharges and no
• Eyelids
discoloration.
Lids close symmetrically and blinks
involuntary.
Transparent with capillaries slightly visible
• Bulbar Conjunctiva

• Palpebral Conjunctiva
Pale

• Sclera Appears white.

• Lacrimal gland, Lacrimal sac, No edema or tenderness over the lacrimal

Nasolacrimal duct gland and no tearing.
CORNEA
• Clarity and Texture Transparent, smooth and shiny upon
inspection by the use of a penlight which is
held in an oblique angle of the eye and
moving the light slowly across the eye.
Has [brown] eyes.
• Corneal Sensitivity Blinks when the cornea is touched through a
cotton wisp from the back of the client.
PUPILS Black, equal in size with consensual and
direct reaction, pupils equally rounded and
reactive to light and accommodation, pupils
constrict when looking at near objects, dilates
at far objects, converge when object is moved
toward the nose at four inches distance and by
using penlight.
VISUAL FIELDS When looking straight ahead, the client can
see objects at the periphery which is done by
having the client sit directly facing the nurse
 at a distance of 2-3 feet.
The right eye is covered with a card and asked
to look directly at the nurse’s nose. Hold
penlight in the periphery and ask the client
when the moving object is spotted.
EAR AND HEARING
• Auricles Color of the auricles is same as facial skin,
symmetrical, auricle is aligned with the outer
canthus of the eye, mobile, firm, non-tender,
and pinna recoils after it is being folded.
• External Ear Canal Without impacted cerumen.

• Hearing Acuity Test Voice sound audible.

• Watch Tick Test Able to hear ticking on right ear at a distance

of one inch and was able to hear the ticking
on the left ear at the same distance.
NOSE AND SINUSES
• External Nose Symmetric and straight, flaring noted,
uniform in color, air moves freely as the
clients breathes through the nares.
• Nasal Cavity Mucosa is light pink, no lesions and nasal
septum intact and in middle with no
tenderness.
MOUTH AND OROPHARYNX Symmetrical, pale lips, brown gums and able
to purse lips.
• Teeth No dental carries

• Tongue and floor of the mouth Central position, pale, with veins prominent
in the floor of the mouth.

• Tongue Movement Able to move when asked to move without.

UVULA Positioned midline of soft palate.
GAG REFLEX Present which is elicited through the use of a
tongue depressor.
NECK Positioned at the midline without tenderness
and flexes slowly. No masses palpated.
HEAD MOVEMENT Coordinated, smooth movement with no
discomfort, head laterally flexes, head
laterally rotates and hyperextends.
MUSCLE STRENGTH With equal strength. Easily fatigability when
moving.
LYMPH NODES Non-palpable, non-tender.
CARDIOVASCULAR
• Inspection Hyperdynamic precordium.

• Rate and Rhythm Regular sinus rhythm, with tachycardia

(110bpm)
THORAX AND LUNGS
• Posterior Thorax Chest symmetrical
• Anterior Thorax

BREATH SOUNDS With decrease breath sound on bilateral

mid to lower hemithorax with dyspnea.
Finding may be due to the anterior
mediastinal mass as shown on CXR.
Tachypnea RR-26cpm.
ABDOMEN Unblemished skin, uniform in color,
symmetric contour, not distended.
ABDOMINAL MOVEMENT Symmetrical movements cause by
respirations.
UPPER EXTREMITIES Without scars and lesions on both extremities.
LOWER EXTREMITIES
Without scars and lesions on both lower
extremities. But with grade 3+ bilateral bipedal
edema.
MUSCLES Weak but with coordinated movements, only
50% of normal full movement against gravity
and full resistance.
BONES AND JOINTS No deformities or swelling, joints slowly
move smoothly.
MENTAL STATUS
• Language Can express oneself by speech or sign.
But with SOB when continuously speaking.
Express words of anxiety due to current
health status.
• Orientation Oriented to a person, place, date or time.

• Attention Span Able to concentrate as evidence by answering

the questions appropriately.
• Level of Consciousness Awake and alert.

MOTOR FUNCTION
• Gross Motor and Balance Unable to sustain upright posture and steady
Walking Gait gait with opposing arm swing for a long time.

PAIN SENSATION Able to discriminate between sharp and dull

sensation when touched with needle and
cotton.
 III- DISCUSSION OF DISEASE PROCESS

Chief Complaint

- Difficulty of breathing and low blood pressure

Diagnostic Examination and Results

TUMOR MARKER

Date Test Result Interpretation

Lactate Dehydrogenase
January 13, 2021 (LDH) Serum LDH activity is
increased in many tumor
Result: 899 U/L
bearing patients and can be
Normal Range: 81-234U/L used as a prognostic marker.

IMMUNOHISTOCHEMISTRY RESULT

Date Test Result Interpretation

January 19, 2021 LCA, CD20, CD30 The immunomorphological

POSITIVE findings support the diagnosis
of a Non-Hodgkin B-Cell
Lymphoma, consistent with a
Primary Mediastinal Large B
Cell Lymphoma.

IMMUNOLOGY

Date: April 1, 2022

Test Result Reference Range Interpretation

Procalcitonin 4.16ng/ml > 2 to <10 ng/ml Systemic infection

(sepsis)is likely.
SARSCOV2 SWAB

Date Test Result

April 2, 2022 SarsCov2 RT PCR Negative

CT Value- 39

HEMATOLOGY

Date: April 1, 2022

Examination Result Reference Range

Hemoglobin 54 g/L * 120-150 g/L

Hematocrit 0.17L/L* 0.36-0.46L/L

WBC Count 36.8/L * 4.5-11.0x10/L

Date: April 2, 2022

Hemoglobin 85 g/L * 120-150 g/L

Hematocrit 0.26L/L* 0.36-0.46L/L

CLINICAL CHEMISTRY

Date: April 1, 2022

Examination Result Reference Range

Sodium 118.9* 136-145 mmol/L

Albumin 14.4 g/L* 35-50 g/L

RADIOLOGIC EXAM

Date Result/Interpretation Film

CHEST X-RAY

January 13, 2021 Large anterior mediastinal

mass.

Increase in the degree of

April 1, 2022
opacification of the bilateral
mid to lower hemithoraces.
The heart, hemidiaphragms
and costophrenic sulci are
obscured. Findings may be
due to the anterior
mediastinal mass and
presence of pneumonia.

CHEST ULTRASOUND
Thick pleural peel is seen in
January 14, 2021
the right posterior hemithorax
with maximum thickness of
0.8 cm
Impression: anterior
mediastinal mass. Suggest
CT scan correlation
CHEST CT SCAN
Large lobulated anterior
November 10, 2020
mediastinal mass is seen with
low density areas. It
measures 10.8 x 17.1 x 15.8
cm

This may represent a

lymphoma.

a. Invasion of the
pericardium associated
with minimal pericardial
effusion.

b. Encasement of the
inferior vena cava
causing moderate
narrowing.
c. Encasement of the left
innominate vein with
thrombus formation.
d. Encasement of the
ascending aorta,
aortic arch, proximal
coronary arteries,
aortic arch branches,
and main pulmonary
artery.
 A massive, well-defined,
March 25, 2022
heterogenously enhancing
anterior mediastinal mass is
noted measuring
approximately 13.2 x 19.8 x
16.7 cm. It exhibits internal
calcifications and
hypodensities. The mass
extends caudally with a large
abdominal component
measuring approximately 7.3
x 10.6 x 11.3 cm. The mass
encases and compresses the
SVC and right pulmonary
artery.
Treatment Summary

Day 1 April 1, 2022 (ER)

- Admitted at Covid Hospitainer (ER COVID Critical) under pulmonary service.

- Started IV antibiotics and prednisone.

- Inotropics (Norepineprine and Dobutamine) started and maintained

- Fall and Reverse Isolation Initiated

- Secured 4 unit PRBC for transfusion.

- Referred to Dietary for nutritional buildup, and increase in sodium and albumin in
meals

- Human Albumin Infusion Started

- Repeat Covid RT PCR with CT Value requested done

- Serum Sodium Monitoring requested every 6 hours

Day 2 April 2, 2022 (Covid Hospitainer)

- Blood Transfusion started

- Repeat CBC done post 2nd unit and continuity of blood transfusion of 3rd and 4th
unit was ordered

- Repeat CBC post 4th unit transfusion of PRBC done

- Discontinued Dobutamine drip and decreased Norepinephrine Drip at 0.1 MKM

- IVF decreased at KVO

- Request for Serum Sodium extraction decreased to daily

- Repeat RTPCR results: Negative

- With plans to resume Chemotherapy

- Transferred to RICU (Non COVID ICU) for further treatment and monitoring
Treatment and Medication

PROCEDURES

1. Oxygen Therapy (1LPM via Nasal Cannula)

- Have limited ability to deliver a precise oxygen concentration in various respiratory
breathing patterns, therefore, the concentration of oxygen cannot be guaranteed.

Nursing Responsibility:
- Explain about the dangers of lighting matches or smoking cigarettes, cigars, or pipes.
Be sure the client has no matches, cigarettes, or smoking materials in the bedside
table. Rationale: Oxygen is highly combustible.

- Use caution with all electrical devices, such as heating pads, electric blankets, or the
ordinary call light. Many healthcare facilities provide call lights with grounding
devices or give such clients tap bells instead. Rationale: Oxygen is highly
combustible.

- Encourage or assist the client to move about in bed. Many clients are reluctant to
move because they are afraid of the oxygen apparatus. Rationale: Movement helps to
prevent hypostatic pneumonia or circulatory difficulties.

- Make sure the tubing is always patent and that the equipment is working properly
Rationale: To be effective, the client needs to receive the proper concentration of
oxygen.

- Monitor document and report the client’s condition regularly Rationale: Regular
observations and detection of potential or existing problems are necessary to
determine the effectiveness of oxygen therapy.

- Provide frequent mouth care. Make sure the oxygen contains proper humidification.
Rationale: Oxygen can be drying to mucous membranes.
 - Discontinue oxygen use only after a physician has evaluated the client. Generally,
you should not abruptly discontinue oxygen given in medium-to-high concentrations
(>30%). Gradually decrease it in stages and monitor the client’s arterial blood gases
or oxygen saturation level. Rationale: These steps determine whether the client needs
continued support

2. Blood Transfusion
Nursing Responsibilities:

- Verify doctor’s order. Inform the client and explain the purpose of the procedure.
- Check for cross matching and typing. To ensure compatibility
- Obtain and record baseline vital signs
- Practice strict asepsis
- At least 2 licensed nurse check the label of the blood transfusion. Check the
following:
o Serial number
o Blood component
o Blood type
o Rh factor
o Expiration date
o Screening test (VDRL, HBsAg, malarial smear) – this is to ensure that the
blood is free from blood-carried diseases and therefore, safe from transfusion.
- Warm blood at room temperature before transfusion to prevent chills.
- Identify client properly. Two Nurses check the client’s identification.
- Use needle gauge 18 to 19 to allow easy flow of blood.
- Use BT set with special micron mesh filter to prevent administration of blood clots
and particles.
- Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes. Adverse
reaction usually occurs during the first 15 to 20 minutes.
- Monitor vital signs. Altered vital signs indicate adverse reaction (increase in temp,
increase in respiratory rate)
- Do not mix medications with blood transfusion to prevent adverse effects. Do not
incorporate medication into the blood transfusion. Do not use blood transfusion lines
for IV push of medication.
- Administer 0.9% NaCl before, during or after BT. Never administer IV fluids with
dextrose. Dextrose based IV fluids cause hemolysis.
- Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets,
cryoprecipitate, transfuse quickly (20 minutes) clotting factor can easily be destroyed.
- Observe for potential complications. Notify physician.
MEDICATIONS

1. Dobutamine (500mg in d5w 50 ml at 5mkm, max dose of 2.2 mKm)

Classification: Inotropics

Nursing Responsibility:

- Monitor BP, heart rate, ECG, cardiac output, and urinary output continuously during
the administration. Report significant changes in vital signs or arrhythmias. Consult
physician for parameters for pulse, BP, or ECG changes for adjusting dose or
discontinuing medication.
- Palpate peripheral pulses and assess appearance of extremities routinely during
dobutamine administration. Notify health care professional if quality of pulse
deteriorates or if extremities become cold or mottled.

2.Norepineprine (10mg in PNSS 90 ml at 0.5 mom (max dose of 3.3 mKm)

Classification: Therapeutics Vasopressor

Indication: Produces vasoconstriction and myocardial stimulation, which may be required after
adequate fluid replacement in the treatment of severe hypotension and shock.

Nursing Responsibility

- Assess blood pressure periodically and compare to normal values. Report a sustained
increase in blood pressure (hypertension) to the physician.

- Assess heart rate, ECG, and heart sounds, especially during exercise. Report a slow
heart rate or symptoms of other arrhythmias, including chest pain, palpitations,
shortness of breath, fainting, and fatigue/weakness.
 - Monitor signs of metabolic acidosis, including headache, lethargy, stupor, seizures,
vision disturbances, increased respiration, cardiac arrhythmias, weakness, and GI
symptoms (nausea, vomiting, abdominal pain). Notify physician or nursing staff
immediately if these signs occur.

- Be alert for signs of hyperglycemia, including confusion, drowsiness, flushed/dry skin,

fruit-like breath odor, rapid/deep breathing, polyuria, loss of appetite, and unusual
thirst. Patients with diabetes mellitus should check blood glucose levels frequently.

- Monitor and report signs of CNS toxicity, including anxiety, restlessness, insomnia, or
tremor. Sustained or severe CNS signs may indicate overdose or excessive use of this
drug.

- Assess IV site during and after IV administration, and report signs of phlebitis (local
pain, swelling, inflammation)

3. Prednisone 100mg tab every 8 hrs

Classification: Corticosteroid (intermediate acting), Glucocorticoid, Hormone

Indications :

- Short-term management of various inflammatory and allergic disorders.

- Hematologic disorders: MS and palliation in some leukemias and lymphomas

Nursing Responsibilities:

- WARNING: Taper doses when discontinuing high-dose or long-term therapy to avoid

adrenal insufficiency.
- Report unusual weight gain, swelling of the extremities, muscle weakness, black or tarry
stools, fever, prolonged sore throat, colds or other infections, worsening of the disorder
for which the drug is being taken.

4. Human albumin 25%

Indications: Hypovolemia and Hypoalbuminemia

Nursing responsibilities:

- Prior to administration, parenteral drug products should be inspected visually for

turbidity and discoloration.
- The healthcare provider must remember not to dilute with sterile water for injection.
- Solutions of Albumin (Human) 20% which are cloudy or have deposits, must not be
used and once the infusion container has been opened the contents should be used
immediately.
- The unused portion must also be discarded.

5. Furosemide 20 mg
Indication : Loop Diuretic

- Decreases renal vascular resistance and may increase renal blood flow.

Nursing Responsibilities:

- Observe patients receiving parenteral drug carefully; closely monitor BP and vital
signs. Sudden death from cardiac arrest has been reported.
- Monitor for S&S of hypokalemia. Report muscle cramps or weakness to physician.
-
- Monitor BP during periods of diuresis and through period of dosage adjustment.
- Observe older adults closely during period of brisk diuresis. Sudden alteration in fluid
and electrolyte balance may precipitate significant adverse reactions. Report
symptoms to physician.
- Monitor I&O ratio and pattern. Report decreases or unusual increase in output.
Excessive diuresis can result in dehydration and hypovolemia, circulatory collapse,
and hypotension. Weigh patient daily under standard conditions.
- Ingest potassium-rich foods daily (e.g., bananas, oranges, peaches, dried dates) to
reduce or prevent potassium depletion.
- Avoid replacing fluid losses with large amounts of water.
 6. Ceftazidime 8 mg

Indication: Treatment of respiratory tract infections.

Nursing responsibilities:

- WOF hypersensitivity or allergic reactions

- Always wash hands thoroughly and disinfect equipment (whirlpools,

electrotherapeutic devices, treatment tables, and so forth) to help prevent the spread
of infection. Employ universal precautions or isolation procedures as indicated for
specific patients.

- Instruct patient to notify immediately of signs of superinfection, including black,

furry overgrowth on tongue, vaginal itching or discharge, and loose or foul-smelling
stools.

7. Hydrocortisone 100mg IV STAT

Therapeutic: Anti-inflammatories (steroid)

Pharmacologic: Corticosteroids

Nursing Responsibilities:

! Monitor signs of hypersensitivity reactions or anaphylaxis, including pulmonary

symptoms (tightness in the throat and chest, wheezing, cough, dyspnea) or skin
reactions (rash, pruritus, urticaria). Notify physician or nursing staff immediately if
these reactions occur.

! Assess any muscle or joint pain. Report persistent or increased musculoskeletal pain
to determine presence of bone or joint pathology (aseptic necrosis, fracture).

! Measure blood pressure periodically and compare to normal values. Report a

sustained increase in blood pressure (hypertension) to the physician.
Background of the Disease
a. GLOBALLY

NHL is predominant in the southern part of Asia as well in America and Canada. Our country
falls in the <5% prevalence rate of this disease.

According to the online journal: Out of Balance – Systemic Iron Homeostasis in Iron-Related
Dso, ACD or anemia of chronic disease is 42% of the global population; malignancy falls under
this percentage.
Correlating Anemia to NHL is vague that numerous and vast data is found online. Let us just
focus on the country nearest to the Philippines with statistics of Anemia in connection to NHL.

23.3% of NHL has Anemi

23.3% of NHL has Anemia according to the statistics from a certain hospital in Indonesia.

b. PHILIPPINES

In the Philippines, 46% of cancers are of other forms and this is where NHL falls under.
NHL comprises 30% of all cancers in the Philippines

c. LUNG CENTER OF THE PHILIPPINES

Total of 5 cases of NHL seen at ER in the year 2021
Pathophysiology

NON-HODGKINS LYMPHOMA

Modifiable Risk Factor Non-Modifiable Risk Factors

Smoker (2-5 pack years); Sedentary Lifestyle; Age (29)
Stress B Cell Lymphoma more common to younger age

Classic B Cell Lymphoma

Symptoms
Fever (Highest 38.1)
Weight Loss (33kgs)
Night Sweats

A. Chest X-ray shows large anterior mediastinal mass (1-14-21) éLDH – 889 U/L
B. Ultrasound of the Chest shows Anterior Mediastinal Mas.
Suggest CT Scan correlation (01-14-21)
C. Chet CT (Plain) shows Large Anterior Mediastinal Mass with
Mass effect measures 10.8x17.1x15.8cm
Chest CT

Immunohistochemistry
(+) LCA, CD20, CD30
B Cell Genetic Mutation
NHL with Primary Mediastinal B Cell Proliferation
Large B Cell Lymphoma B Cell Divides uncontrollably
Ann Arbor Stage: Stage 1 with B
Symptoms (January 2021) Neoplastic Cell
ê
Treatment: 2 Line Chemo Affecting the Mediastinum (+)
(Vincristine) Mediastinal Mass
4 Sessions Radiotherapy

Metastasis
Diagnostics:
a. Chest X-ray é Opacities of bilateral mid to lower hemi
thorax findings may be due to mediastinal mass (04-01-22)
b. CT Scan: Massive anterior mediastinal mass with
abdominal extension, mass effect, narcotic components (03-
25-22)

Size: Anterior mediastinal mass approximately 13.2x19.8x16.4cm

The mass extends gradually with large abdominal components measuring 7.2x10.6x11.3cm
- Compresses the SVC and right pulmonary artery

S/Sx: Weight loss; Shortness of Breath (2 nasal flaring); Fatigue

NHL with Primary Mediastinal Large B Cell Lymphoma

Ann Arbor Stage: Stage IV with B Symptoms
Treatment: Prednisone, For Chemo once anemia is corrected
 Normal Physiology in the Bone Marrow

Bone Marrow Bone Marrow

(Primary Lymphoid Organ)
Produce RBC In response to
Produce Pre-cursor B Cells erythropoietin
Hemoglobin release by the
Becomes Naïve B-Cells binds to O2 kidney due to
(t/2 120 Days) low O2 level in
Travels to the Lymphatic Nodes the blood
(Secondary Lymphoid Organ) Moves to all tissue in
our body
Fight infection if present

Will undergo Apoptosis

(Programmed Cell Death)

But with NHL

B Cells Undergo Genetic mutation

B Cell Proliferation
(B Cells divides uncontrollably)

Neoplastic Cells
CD20, CD 30 B Cells
 ANEMIA OF CHRONIC ORIGIN

Non-Modifiable Risk Factors Modifiable Risk Factors

NHL extra nodal lymphoma Chemotherapy & Radiation
affecting Bone Marrow
Targets cells with high turnover
Crowds out normal progenitor cell like the bone marrow
production
Affects myeloid progenitor cells
(Precursor to blood cells such as
RBC/Erythrocytes)

Decrease production of RBC Myelosuppression

Decreased bone marrow activity

Decrease production of RBC

Anemia

S/Sx: Easy fatigability; Shortness of Breath, Nasal Flaring

Pale Skin & Palpebral lips, tongue; Poor capillary refill (>3sec)

Vs: BP 84/53 ; HR 110 ; RR 26

Diagnostics:
Hg – 54g/l (N 120-150g/l)
Hct – 0.17L/L (N 0.36-0.46L/L)

Treatment and Nursing Care:

O2 Therapy- 1 lpm n/c
Blood Transfusion- 4 units PRBC
Erythropoietin Injection
Complete Bed Rest
 Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)

Modifiable Risk Factors Non- Modifiable Risk Factors

Chemotherapy (Vincristine) B Cell Lymphoma
Radiotheraphy (Hematological Malignancy)
Stress

Neurotoxic Effect on Altering normal osmotic control of

hypothalamus Pituitary Axis ADH Secretion

Ectopic production of Arginine

Vasopressin (AVP) in the posterior
Increase fluid retention in the body pituitary gland

S/Sx: Urine Specific Hyponatremia : Decrease urine output

Shortness of Breath Gravity 1.015 118.9 mmol/L Intake – 1,310ml
Headache (N 1.005 – 1.030) (N 135-145mmol/L) Output – 400ml
Agitation Hypoalbuminemia Bipedal Edema Grade 3+
14.4g/L Moderately Severe pitting
(N25-50g/L) edema 6mm depression that
last more than 1 minute

Management

Strict I & O Pharmacologic: Diet

Serum Monitoring Q6 Albumin 25% vial é Na intake
Seizure Precaution Furosemide
Chemotherapy when
anemia is corrected
 SEVERE SEPSIS

Modifiable Risk Factors Non- Modifiable Risk Factors

Chemotherapy NHL Extra nodal bone marrow
Radiation affectation

Targets cells with high turnover

like bone marrow

Hemapoeietic and Immune system dysfunction

Immunosuppression & Anemia

Covid Infection (+) SarsCov2 RTPCR

Bilateral mid to lower opcification of bilateral hemithorax
Macrophage and monocytes activation
éWBC 368/L

Overwhelming Inappropriate Response

Mast cells release inflammation mediators, cytokines,

interleukins, tumor necrosis factors

éProcalcitonin 4.16mg/ml Treatment:

Indicating systemic infection (Sepsis) Ceftazidime 2g IV, Prednisone tab

Excess Mediators: Increase O2 Consumption

Increase vascular permeability Tachypnea – 26bpm
Shunt flow Hypovolemia Tachycardia – 110bpm
Vasospasm Treatment: O2 Therapy
Vasodilation
Leakage plasma into interstitium ê Venous Return êPreload êCardiac Output

Hypotension:
Increase tissue hypoxia 83/53mmHg
Cellular insufficiency Inadequate Tissue Perfusion Treatment:
Mitochondrial Dysfunction Cool and pale skin Norepinephrine Drip
Decrease urine output & Dobutamine
PNSS 1L x 60cc/hr
IV- FOCUS CHARTING
1. F - Impaired Airway Clearance

D - Rapid, shallow breathing, on orthopneic position.

- Large Anterior Mediastinal compresses the SVC and right pulmonary artery
as shown on diagnostics imaging.
- RR=32 and O2 saturation of 96% at room air.
A - Maintained on upright sitting position.

- Encouraged deep breathing exercises

- Placed on complete bed rest without bathroom privileges

- Oxygen @1LPM via nasal cannula as ordered

- Hydrocortisone 100mg IV given as ordered

- Monitored for desaturation and respiratory distress

R - Temporary relief from forceful breathing noted, RR=24.

- Oxygen Saturation of 98-100% at 1 LPM via nasal cannula.

2. F - Ineffective Tissue Perfusion as Evidenced by Low Blood Pressure

D - Cold, clammy, pale skin and mucosa.
- Generalized body weakness.
- Shortness of breath.
- BP = 84/53mmHg, Pulse Rate of 110 bpm.
A - Lower extremities slightly elevated.
- Maintained activity restrictions.
- Provided calm and restful surroundings.
- Kept patient warm.
- Intravenous fluid regulated as ordered.
- Administered and regulated inotropic and vasopressors as ordered
- Watch out for sudden increase in blood pressure and pulse rate
R - Maintained adequate perfusion. Latest BP =91/64mmHg PR of 100 bpm.
3. F - Fatigue Related to Diminished Oxygen-Carrying Capacity of the Blood.
D. - “Hinang hina ang pakiramdam ko, ang bilis ko hingalin kahit kunting galaw
lang” as verbalized.
- Exertional discomfort and dyspnea.
- Inability to maintain usual level of physical activity.

- Increased rest requirements.

- Generalized body weakness.

- Hg- 54 g/L *, Hct- 0.17L/L*

A - Enforced complete bed rest.

- Provides supplemental oxygen as ordered. 1lpm nasal cannula.

- - Facilitates ordered blood transfusion of 4 units PRBC properly typed and

crossmatched. Able to transfuse 2 units of PRBC.

- Monitor hemoglobin, hematocrit and RBC counts.

- Educate energy- conservation technique.

R - “Medyo lumakas ng kunti pakiramdam ko, pero hindi pa din tulad ng dating
normal na lakas ng katawan ko. Nakaka upo na ako at higa ng hindi mabilis
hingalin.” as verbalized.

- Able to understand health teaching on energy conservation.

- Repeat Hg- 85g/L*, Hct-0.26L/L*
- Still in need of supplemental oxygen.
V- KNOWLEDGE GAINED FROM THE CASE STUDY

1. Familiarized with the clinical, anatomical, and pathophysiological background of Non-Hodgkin’s

B-Cell Lymphoma, Chronic Anemia, SIADH and Severe Sepsis.
2. Review the multimodal diagnosis and treatment of Non-Hodgkin’s B-Cell Lymphoma, Chronic
Anemia, SIADH and Severe Sepsis.
3. Appreciate anatomy and correlation of each of the condition.
4. Review of the nursing responsibilities and management in blood transfusion.
5. Grasp knowledge and practices towards the disease.
VI- SUGGESTION AND RECOMMENDATION

1. As the number of Covid cases subsides, many patients with malignancy cases like
NHL are being seen and examined in different hospitals and even in LCP.
Because of this we suggest conducting seminars and lectures regarding
management of NHL and other related conditions to keep nurses refreshed and
updated with their knowledge on the following cases.
2. Recommending a clinical pathway on management on NHL and other related
conditions. Also, a clinical pathway for anemia and related conditions.
3. A designated area in the ER, like isolation room to temporarily hold
immunocompromised patients when seen in the ER if consulted without swab
result. To avoid exposure to actively and highly infectious patients.
4. To help people with Non-Hodgkin’s Lymphoma (and their family members) to
make decision about care, we recommend improving/ creating of a support group
and palliative care for adults with cancer and care of dying patient in the last days
of life.
VII- REFERENCES
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4. Gross AJ, Steinberg SM, Reilly JG, et al. Atrial natriuretic factor and arginine
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5. Raftopoulos H. Diagnosis and management of hyponatremia in cancer

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