1

Professional Experience Summary: Multiple Myeloma

Megan Lind

The University of Mary

NUR 319: Pathophysiology

Professor Tara Hovda

August 14, 2022

 2

Professional Experience Summary on Multiple Myeloma

During my clinical practice I encountered a patient with a rare cancer called multiple

myeloma. The pathophysiology of this rare plasma cell cancer involves many factors, and the

treatment, prognosis, and the nursing interventions we can implement are instrumental to the

understanding of the disease. However, to understand how to treat multiple myeloma we must

first acquire a patient history including the patient’s history with the illness, her individual risk

factors, her symptoms, and why she sought care. We must then understand what multiple

myeloma is, its pathophysiology, and how its pathophysiology correlates with the symptoms we

see. We must also understand all of the risk factors for the disease and its genetic component.

Only then can we dive into how to treat multiple myeloma, its disease progression, our patient’s

outcomes, and what we need to educate our patient on to make her treatment as successful as

possible. To truly understand the pathophysiology of multiple myeloma, we must reach into

personal experience to achieve a complete picture of the disease.

Patient Presentation

To explore the pathophysiology of multiple myeloma, first covered will be a brief history

of the patient’s disease. This will include her gender, race, and age. This will also include her

care history, with brief summaries as to why she continued to seek further care. Next, we will

discuss her risk factors, as well as her symptoms related to her multiple myeloma. Finally, we

will discuss her reasoning for seeking care.

Brief History

The patient is a 73 year old female. She is caucasian. The patient presented two years ago

with fatigue, a history of anemia, weakness and bone pain in the back. She saw a hematologist
 3

after being referred by her general practitioner. He diagnosed her with iron deficient anemia. Her

white blood cell counts were normal, as well as her vitamin B12 level, and no Rouleaux

formation of red blood cells was noted. She was showing no sign of renal failure, but does suffer

from gastroesophageal reflux disease. Her CBC with differential, blood chemistry panel, and her

Ig blood levels all came back normal. She continued following up with her hematologist until she

transferred providers. This is two years after the initial onset of her symptoms. Then she was

given a bone marrow biopsy. This found twelve percent of the plasma cells in her bone marrow

showed proliferation. No tumors made up of plasma cells were noted on her PET scan. Her

hemoglobin values are now 7 mmol/l. Due to this she is experiencing weakness and fatigue. Her

B12 level is also reduced. She has had multiple infections in the past year, as a result of her

proliferated platelets. Her serum beta-2-microglobulin is 5.6 mg/l, and her serum LDL is high.

She is considered stage III.

Risk Factors

Multiple Myeloma does not have any known risk factors, as its cause is unknown. It is

possibly associated with exposure to radiation, age, gender, family history, weight and exposure

to harmful chemicals (Knudsen, 2020). The patient was exposed to asbestos, which is a known

harmful carcinogen. She was not exposed to radiation often, as her only exposure has come from

a few X-rays throughout her lifetime. The patient is at risk due to her age, she is 73 years old.

She is also at risk due to her gender. Multiple myeloma is more common in females and the

patient is female. Another risk factor she has is weight, she is obese. Being overweight or obese

has been correlated with developing multiple myeloma, as well as causcasian decent. The patient

is caucasian, which also increased her risk of developing the disease.

 4

Clinical Manifestations

The patient’s symptoms are persistent fatigue, malaise, and bone pain which is strongest

in her back but intermittently occurs in her legs and ankle. Due to her anemia she also

experiences weakness and dizziness. She often sleeps ten to twelve hours a night due to her

fatigue, and if she cannot get that much sleep she will nap throughout the day. She is unable to

participate in many physical activities, and often has trouble getting out of bed. Due to her

compromised immune system she has experienced. Her hemoglobin and B12 are low and her

serum LDL is high. Her serum beta-2-microglobulin is 5.6 mg/l, and her white blood cell count

is low. She recovers slowly from infections, and bruises easily. She also is hypercalcemic.

Reason For Seeking Care

She originally sought medical care because she was so tired it was becoming difficult to

keep up with her lifestyle, and because her back hurt. She has been experiencing pain and fatigue

as well as anemia for two years. She had been through previous doctors that told her she did not

appear to suffer from any back issues, other than osteoarthritis. However, she was concerned this

pain was more than her normal arthritis pain. She found it difficult to get up, and was too weak

to play with her grandkids somedays. These sudden changes indicated something was wrong,

and the progression of her disease caused her to see specialists to get her diagnosis.

The diagnostic tests she received were a bone biopsy, which revealed twelve percent

proliferation of her plasma cells. She required a CBC with differential, a blood chemistry panel,

a serum protein electrophoresis, a urine electrophoresis, and a beta-2-microglobulin level test.

She also got a PET scan and an X-ray, as well as a bone density test. She also required an

electrocardiogram.
 5

Multiple Myeloma

Multiple myeloma is a cancer of the plasma cells in the bone marrow, and arises in the B

lymphocytes. It is a hematologic neoplasm. It is also known as Kahler disease, myelomatosis,

and plasma cell myeloma. I will first discuss the pathophysiology of multiple myeloma. Then, I

will discuss how the pathophysiology of multiple myeloma causes the symptoms we see

associated with it. Finally, I will discuss the additional risk factors for multiple myeloma my

patient does not have, as well as the genetic factors of the disease (Capriotti, 2020).

The Pathophysiology of Multiple Myeloma

Multiple myeloma arises in the B lymphocytes. As these B lymphocytes mature into

plasma cells they cause uncontrolled proliferation. This proliferation occurs in the bone marrow,

where the plasma cells in the bone marrow line their ability to properly produce

immunoglobulin. This is because of overcrowding from the groups of proliferated cells. The

healthy white and red blood cells, as well as the platelets are not produced in high enough

quantities. This leads to hypoxia from a lack of red blood cells. The bone cells are not able to

remodel in the way they do when the cancer is not present (Capriotti, 2020).

This leads to osteolytic lesions, bone pain, anemia, leukopenia, thrombocytopenia and

hypercalcemia. The lesions are a result of these “clumps” of proliferated B lymphocytes. They

overcrowd the healthy cells and lead the cytokines in these proliferated cells increasing

osteoclastic activity. One of these cytokines is interleukin-6 (IL-6). This cytokine secretion

changes growth factor-β. Multiple myeloma cells release different types of growth factors

(TGF-β and IL-6). These growth factors alter the expression of stem cells. These stem cells are

important for the production of the proteins involved in protein reabsorption and without them
 6

bone resorption accelerates. This is due to those same stem cells inhibiting the anti-osteoclast

activity of estrogens, and osteoblastic activity becomes inhibited as well (Boa et al., 2020).

Multiple myeloma cells also attach to stromal elements of normal cells, this inhibits their

osteoblastic activity. This attachment also allows for the malignant cells to survive and grow.

However, these attachments serve another interesting purpose, they allow bone marrow cells and

multiple myeloma cells to communicate. This allows for even more rapid multiplication. This

leads to hypoxia of the healthy cells. All of these factors combine together to destroy the bone

and disable the cells from forming new bone. This bone destruction releases calcium into the

blood. The mutations in the plasma cells cause the normally two chained identical Ig in the

plasma to become much more numerous or fragment. The most common Igs that proliferate are

called IgG and IgA. IgG makes up 60% of the malignancy. When the amount of circulating Igs

gets high like with multiple myeloma the blood becomes thicker (Saba et al., 2018).

Through all of these processes, the increased bone destruction, and the restriction of the

creation of new healthy cells plasmacytomas form. These are tumors which are formed by the

malignant plasma cells in the bone. The bone started to appear almost porus, with small areas

having holes in them. This weakens the bones and reduces the number of healthy cells. The more

multiple myeloma cells there are the faster they grow and divide due to the increased control of

the stromal cells. This slowly suffocates more and more healthy cells forming more and more

plasmacytomas. The amount of red blood cells, white blood cells, and platelets in the blood

continues to decrease with this growth. This makes the patient more anemic, more susceptible to

infection, and stops them from being able to oxygenate themselves as well (Saba et al., 2018).
 7

Clinical Manifestations Related to Pathophysiology

What is the relationship between this pathophysiology and the symptoms we see with

multiple myeloma? One of the landmark symptoms for multiple myeloma is hypercalcemia.

Hypercalcemia is considered a total plasma concentration of greater than 10.5 mg/dl. The type of

hypercalcemia we see due to multiple myeloma is called hypercalcemia of malignancy or HCM.

HCM develops in multiple myeloma due to the presence of osteolytic metastases. These

metastases cause increased osteoclastic activity in the bone marrow, which releases calcium into

the bloodstream. Multiple myeloma tumors also produce vitamin d, which causes the bones to

release calcium. This hypercalcemia then causes its own subset of symptoms, such as excessive

thirst, lethargy, renal dysfunction and confusion (Capriotti, 2020).

Proliferation in multiple myeloma also causes overcrowding within the bone marrow.

This causes disturbances in the production of white blood cells, red blood cells, and plasma. Due

to a lack of white blood cells we see frequent infection. When there are not enough white blood

cells to fight infection, we are more susceptible to infection, and these infections will take longer

to heal. This lack of red blood cells will cause poor oxygenation due to low hemoglobin, which

carries oxygenated blood to parts of the body. The overabundance of immunoglobulin also

overwhelms the kidneys. The kidneys cannot filter this immunoglobulin fast enough, which

results in kidney failure (Capriotti, 2020).

The bone pain we see with multiple myeloma is caused by the bone destruction and

weakening we see with multiple myeloma. When the bones become weaker and release more

calcium, the bones compress and collapse. It is common with multiple myeloma to compress

nerves in the lumbosacral area. This collapse also causes the loss of height which we see with

multiple myeloma. This collapse can also lead to radiculopathy, caused by the neoplastic plasma
 8

cell tumor. Multiple myeloma also brings anemia due to the low hemoglobin caused by the

impaired production of red blood cells because of overcrowding. This anemia causes weakness,

pallor, and fatigue. These symptoms are due to the lack of oxygenation we see (Capriotti, 2020).

Additional Risk Factors

Other risk factors for multiple myeloma not seen in the patient include a family history of

multiple myeloma. No one in the patient's family has ever been diagnosed with multiple

myeloma. Other risk factors the patient does not have include exposure to agent orange, which

the patient has not experienced. As well as, exposure to excessive radiation. The patient has only

had a few X-rays in her lifetime. She was never involved in an exposure to radioactive waste.

However, the patient has many other risk factors associated with multiple myeloma, such as age,

race, weight, and gender (Knudsen, 2020) .

Genetics of Multiple Myeloma

Although the cause of multiple myeloma is unknown a genetic component to the disease

has been identified. There is evidence of multiple myeloma running in families however, it is

unknown which gene this is related to. It is also unknown how this gene is passed down through

generations. It is also unknown how likely it is to be passed down. Multiple myeloma causes

chromosomal mutations in the patient. Trisomies of odd chromosomes begin to occur.

Rearrangements involving the IGH gene occur early in the disease. Later in the disease we see a

loss of chromosomes 13 and 17p. Although we do not understand how these changes can affect

heredity, we know they happen and it is speculated this ability to alter chromosomes could be

why we see heredity (Oliva et al., 2021).

Treatment for Multiple Myeloma

 9

This patient has not received treatment for her multiple myeloma. She initially went

undiagnosed for two years when she was in the early stages of the disease. Multiple myeloma is

often difficult to diagnose. She now has decided due to her old age, and because of how

chemotherapy and radiation are likely to affect her body that she would prefer not to seek

treatment. She is instead opting for monitoring of her disease and treatment of her symptoms.

This includes iron infusions intravenously, to treat her anemia. She is also utilizing pain

management for her bone pain. She gets routine blood work every three months to track the

progression of the disease. This will monitor the calcium levels in her blood through a basic

metabolic panel. This will also track her B12 levels. She also receives a bone biopsy every six

months. This allows us to track the percentage of proliferated cells in her bone marrow. She also

receives a PET scan every six months to monitor for metastasis (Capriotti, 2020).

Typical treatment of this disease involved chemotherapy, radiation, and stem cell

transplantation. The lesions or neoplastic plasma cell tumors (plasmacytoma), are targeted with

chemotherapy and radiation. The tumor is radiated, then chemotherapy medications are used to

reduce spreading. Osteoclastic activity is reduced through bisphosphate therapy. This limits the

breakdown of the patient's bones, which reduces bone pain, hypercalcemia, and vertebral

destruction (Caprriotti, 2020).

Patient Outcome and Progression

Unfortunately due to the patient’s age and lack of treatment her multiple myeloma will

likely prove fatal. She will likely acquire an infection her body is unable to fight off such as a

staph infection. She may become septic, and will die from complications of the disease, not the

multiple myeloma itself. It is possible her weakness will lead to falls, and immobility, which

could also lead to death. As her disease further progresses she will experience increased anemia,
 10

hypoxia, bone pain, bone damage, loss of height, loss of mobility, infection, hypercalcemia, and

renal distress. Her kidneys will fail due to chronic hypercalcemia. She will experience fluid

retention issues. She will likely have to undergo dialysis. She will need treatment for infections.

She will experience low oxygen saturation, and increasingly impaired healing (Capriotti 2020).

If the patient were to undergo chemotherapy, multiple myeloma is practically incurable,

especially in the later stages. If the patient underwent chemotherapy it would only reduce the

amount of tumors in the marrow from proliferation. However, as a result of the chemotherapy the

patient would experience nausea, weight loss, hair loss, pain, and many other symptoms.

Chemotherapy would have its own long term effects on the patient's body. With chemotherapy

the patient could live a longer life, however we must also consider quality of life. In the end the

patient made the decision in her treatment, to not undergo life prolonging measures. She is

instead managing her symptoms. Multiple myeloma most often causes death due to kidney

failure from a buildup of calcium deposits from chronic hypercalcemia. This is what would most

likely cause the patient’s death.

Educational Topics

Three points the nurse should educate the patient on are diet, mobility, and pain

management. The diet of the patient needs to be addressed to aid in an improvement of her

quality of life. Cancer patients often experience constipations leading to discomfort and a lack of

appetite. The patient will also experience fatigue, a loss of taste, and nausea and vomiting. To

combat these outcomes and improve patient prognosis it is important for the patient to consume

foods high in plant based proteins to obtain vitamins and minerals. It is also important for the

patient to consume healthy fats and healthy carbs to maintain their energy, and to get an adequate

amount of fiber to avoid constipation. It is also important for the patient to avoid foods such as
 11

raw fish, uncooked eggs, unpasteurized dairy products, and unwashed fruits or vegetables. Due

to the patient's multiple myeloma she will experience immunosuppression and it will be

important for her to avoid these foods because they can lead to exposure to pathogens such as e

coli and parasites (2021).

The patient should also remain active and if necessary, complete physical therapy to

retain pain free movement and exercise. To maintain optimal oxygenation that patient must

maintain their cardiovascular health. To do this they should exercise as tolerated. Doing low

impact activities such as swimming, and walking can help to maintain mobility while reducing

pain for the patients. The patient must be educated to continue a healthy lifestyle through activity

and maintain mobility so they can maintain their overall health, and to prevent hypoxia.

Another topic of education will be pain management. The nurse will need to provide the

patient with both education on the uses and side effects of their pain medication. They will also

need to educate the patient on non-pharmacological pain solutions. Many pain medications the

patient will encounter will depress the central nervous system, they may also cause confusion,

disorientation, and fatigue. The nurse will need to educate the patient on fall prevention as a

result of this.

They will also need to educate the patient on non pharmacological pain relief techniques

such as relaxation therapy, distraction, imagery, comfort therapy, physical and occupational

therapy, and psychosocial therapy. Relaxation therapy, distraction and imagery can all provide a

reduction in pain through helping to calm and distract the patient from their pain. Comfort

therapy such as hot and cold compresses, positioning, and massage therapy can help alleviate

their pain and reduce inflammation. Physical and occupational therapy can help the patient to

maintain their quality of life and independence. Psychosocial therapy can maintain their spiritual
 12

and emotional well being, and can help them come to terms with their illness, and maintain the

support they need (2017).

The Role of an LPN in Comparison to a Baccalaureate Nurse

As an LPN I would be in a role which involved performing more nursing skills related to

the patients treatment. As an LPN you could assist your patient with their therapy exercises. The

nurse could also assist them to keep active, by helping the patient ambulate, or to physically or

occupational therapy exercises. You could also assist your patient to apply cold compresses, or

offer them support in coming to terms with their condition. A nurse could assist them with their

imagery therapy or comfort therapy. Nurses would administer their medications, and obtain the

patient’s vital signs. As an LPN I would also proformance physical assessments and report all of

my findings to the RN. If the patient had an infection of the skin I would perform their wound

care services. I would assist the RN in creating the care plan, through my input and knowledge of

the patient. I would also give suggestions for how to improve the patient’s care plan. However, I

would not make those changes.

As a bachelorette RN, I would likely perform all of the nursing skills mentioned before.

However, my role in serving the patient would extend to creating and updating their care plan as

well as delegation of roles, and education. I would develop the patient's plan of care, such as

their diet, activity level, and oversee their pain management. I would assess their risk of falls. I

would also educate the patient about their pain medications and explain to them how to take their

medication, and why we have prescribed it. I would take into account the medications

interactions, and side effects, and educate the patient on these risks. I would delegate roles to

other health care professionals such as LPNs and CNAs. I would also supervise the LPNs and

CNAs as they performed these tasks. I would administer the patient’s iron infusion treatments
 13

and manage all of their medications. I would implement new physicians orders, as well as

communicating my patients stats to the physician. I would take into account the medications

interactions, and side effects, and educate the patient on these risks. I would explain procedures

and physician’s orders to the patient and follow these orders.

 14

References

Boa, L. et al., (2020). Hypercalcemia caused by humoral effects and bone damage indicate poor

outcomes in newly diagnosed multiple myeloma patients. 9(23), 8962-8969.

https://doi/10.1002/cam4.3594

Capriotti, T. (2020). Davis Advantage for pathophysiology: Introductory concepts and clinical

perspectives, (2nd ed., pp. 264-266). F.A. Davis.

Knudsen, K. (2020). Risk factors for multiple myeloma. American Cancer Society. (n.d.).

Retrieved from

https://www.cancer.org/cancer/multiple-myeloma/causes-risks-prevention/risk-factors.ht

ml

Oliva, S. et al., (2021). A longitudinal analysis of chromosomal abnormalities in disease

progression from MGUS/SMM to newly diagnosed and relapsed multiple myeloma.

Annals of hematology, 100(2), 437-443. https://doi/10.1007/s00277-020-04384-w

Saba, F. et al., (2018). New role of hypoxia in pathophysiology of multiple myeloma through

miR-210., 17,647-662. https://doi/10.17179/excli2018-1109

(2017) Management of pain without medications. Stanford Health Care (SHC) - Stanford

Medical Center. Retrieved from

https://stanfordhealthcare.org/medical-conditions/pain/pain/treatments/non-pharmacologi

cal-pain-management.html
 15

(2021) Cancer diet: Foods to add and avoid during cancer treatment. Johns Hopkins Medicine.

Retrieved from

https://www.hopkinsmedicine.org/health/conditions-and-diseases/cancer/cancer-diet-food

s-to-add-and-avoid-during-cancer-treatment