Nursing Management in Bone Marrow Transplantation

Nursing care of patients undergoing BMT is complex and demands a high level of skill. Transplantation nursing can be extremely rewarding yet extremely stressful. The success of BMT is greatly influenced by nursing care throughout the transplantation process.
 

IMPLEMENTING PRETRANSPLANTATION CARE
All patients must undergo extensive pretransplantation evaluations to assess the current clinical status of the disease. Nutritional assessments, extensive physical examinations and organ function tests, and psychological evaluations are conducted. Blood work includes assessing past antigen exposure (for example, to hepatitis
virus, cytomegalovirus, herpes simplex virus, HIV, and syphilis). The patient’s social support systems and financial and insurance resources are also evaluated. Informed consent and patient teaching about the procedure and pretransplantation and posttransplantation care are vital.

PROVIDING CARE DURING TREATMENT
Skilled nursing care is required during the treatment phase of BMT when high-dose chemotherapy (conditioning regimen) and total body irradiation are administered. The acute toxicities of nausea, diarrhea, mucositis, and hemorrhagic cystitis require close monitoring and constant attention by the nurse. Nursing management during the bone marrow or stem cell infusions consists of monitoring the patient’s vital signs and bloodoxygen saturation; assessing for adverse effects, such as fever, chills, shortness of breath, chest pain, cutaneous reactions, nausea, vomiting, hypotension or hypertension, tachycardia, anxiety, and taste
changes; and providing ongoing support and patient teaching. 

Throughout the period of bone marrow aplasia until engraftment of the new marrow occurs, patients are at high risk for dying of sepsis and bleeding. Patients require support with blood products and hemopoietic growth factors. Potential infection may be
bacterial, viral, fungal, or protozoan in origin. Renal complications arise from the nephrotoxic chemotherapy agents used in the conditioning regimen or those used to treat infection (amphotericin B, aminoglycosides). Tumor lysis syndrome and acute tubular necrosis are also risks after BMT. 

GVHD requires skillful nursing assessment to detect early effects on the skin, liver, and gastrointestinal tract. VOD resulting from the conditioning regimens used in BMT can result in fluid retention, jaundice, abdominal pain, ascites, tender and enlarged liver, and encephalopathy. Pulmonary complications, such as pulmonary edema, interstitial pneumonia, and other pneumonias, often complicate the recovery after BMT. (Medical and Surgical Nursing; Brunner & Suddarth10th Edition)

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Posted in: Nursing Management

Classification of Chemotherapeutic Agents

Certain chemotherapeutic agents (cell cycle–specific drugs) destroy cells actively reproducing by means of the cell cycle. Many of these agents are specific to certain phases of the cell cycle. Most affect cells in the S phase by interfering with DNA and RNA synthesis. Others, such as the vinca or plant alkaloids, are specific to the M phase, where they halt mitotic spindle formation.
 

Chemotherapeutic agents that act independently of the cell cycle phases are termed cell cycle–nonspecific agents. These agents usually have a prolonged effect on cells, leading to cellular damage or death. Many treatment plans combine cell cycle–specific and cell cycle–nonspecific agents to increase the number of vulnerable tumor cells killed during a treatment period.

Chemotherapeutic agents are also classified according to various chemical groups, each with a different mechanism of action. These include the alkylating agents, nitrosureas, antimetabolites, antitumor antibiotics, plant alkaloids, hormonal agents, and miscellaneous agents. The classification, mechanism of action, common
drugs, cell cycle specificity, and common side effects of antineoplastic agents.

Chemotherapeutic agents from each category may be used to enhance the tumor cell kill during therapy by creating multiple cellular lesions. Combined medication therapy relies on medications of differing toxicities and with synergistic actions. Using combination drug therapy also prevents development of drugresistant
mechanisms.

Combining older medications with other agents, such as levamisole, leucovorin, hormones, or interferons (IFN), has shown some benefit in combating resistance of cells to chemotherapeutic agents. Newer investigational agents are being studied for effectiveness in resistant tumor lines. For more information about
investigative drugs,

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Posted in: Cancer,Chemotherapy

Nursing Management in Radiation Therapy

The patient receiving radiation therapy and the family often have questions and concerns about its safety. To answer questions and allay fears about the effects of radiation on others, on the tumor, and on the patient’s normal tissues and organs, the nurse can explain the procedure for delivering radiation and describe the equipment, the duration of the procedure (often minutes only), the possible need for immobilizing the patient during the procedure, and the absence of new sensations, including pain, during the procedure. If a radioactive implant is used, the nurse informs the patient and family about the restrictions placed on visitors
and health care personnel and other radiation precautions. Patients also need to understand their own role before, during, and after the procedure. See Chapter 47 for further discussion of radiation treatment for gynecologic cancers.

PROTECTING THE SKIN AND ORAL MUCOSA
The nurse assesses the patient’s skin, nutritional status, and general feeling of well-being. The skin and oral mucosa are assessed frequently for changes (particularly if radiation therapy is directed to these areas). The skin is protected from irritation, and the patient is instructed to avoid using ointments, lotions, or powders
on the area. Gentle oral hygiene is essential to remove debris, prevent irritation, and promote healing. If systemic symptoms, such as weakness  and fatigue, occur, the patient may need assistance with activities of daily living and personal hygiene. Additionally, the nurse offers reassurance by explaining that these symptoms are a result of the treatment and do not represent deterioration or progression of the disease.

PROTECTING THE CAREGIVERS
When a patient has a radioactive implant in place, nurses and other health care providers need to protect themselves as well as the patient from the effects of radiation. Specific instructions are usually provided by the radiation safety officer from the x-ray department. The instructions identify the maximum time that can
be spent safely in the patient’s room, the shielding equipment to be used, and special precautions and actions to be taken if the implant is dislodged. The nurse should explain the rationale for these precautions to keep the patient from feeling unduly isolated. (Medical and Surgical Nursing; Brunner & Suddarth10th Edition)

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Posted in: Nursing Management,Radiation Therapy

Nursing Management for Patient Undergoing Cancer Surgery

The patient undergoing surgery for cancer requires general perioperative nursing care, as described in Unit 4, along with specific care related to the patient’s age, organ impairment, nutritional deficits, disorders of coagulation, and altered immunity that may increase the risk for postoperative complications. Combining
other treatment methods, such as radiation and chemotherapy, with surgery also contributes to postoperative complications, such as infection, impaired wound healing, altered pulmonary or renal function, and the development of deep vein thrombosis. In these situations, the nurse completes a thorough preoperative assessment for all factors that may affect patients undergoing surgical procedures. 

The patient undergoing surgery for the diagnosis or treatment of cancer is often anxious about the surgical procedure, possible findings, postoperative limitations, changes in normal body functions, and prognosis. The patient and family require time and assistance to deal with the possible changes and outcomes resulting from the surgery.

 The nurse provides education and emotional support by assessing patient and family needs and exploring with the patient and family their fears and coping mechanisms, encouraging them to take an active role in decision making when possible. When the patient or family asks about the results of diagnostic testing and surgical procedures, the nurse’s response is guided by the information the physician previously conveyed to them. The patient and family may also ask the nurse to explain and clarify information that the physician initially provided but that they did not grasp because they were anxious at the time. It is important for the nurse to communicate frequently with the physician and other health care team members to be certain that the information provided is consistent. 

After surgery, the nurse assesses the patient’s responses to the surgery and monitors for possible complications, such as infection, bleeding, thrombophlebitis, wound dehiscence, fluid and electrolyte imbalance, and organ dysfunction. The nurse also provides for patient comfort. Postoperative teaching addresses wound care, activity, nutrition, and medication information.

Plans for discharge, follow-up and home care, and treatment are initiated as early as possible to ensure continuity of care from hospital to home or from a cancer referral center to the patient’s local hospital and health care provider. Patients and families are also encouraged to use community resources such as the American Cancer Society or Make Today Count for support and information. (Medical and Surgical Nursing; Brunner & Suddarth10th Edition)

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Posted in: Brunner,Cancer

Diagnosis of Cancer and Related Nursing Considerations

A cancer diagnosis is based on assessment for physiologic and functional changes and results of the diagnostic evaluation. Patients with suspected cancer undergo extensive testing to

(1) determine the presence of tumor and its extent,
(2) identify possible spread (metastasis) of disease or invasion of other body tissues,
(3) evaluate the function of involved and uninvolved body systems and organs, and
(4) obtain tissue and cells for analysis, including evaluation of tumor stage and grade.

The diagnostic evaluation is guided by information obtained through a complete history and physical examination. Knowledge of suspicious symptoms and of the behavior of particular types of cancer assists in determining which diagnostic tests are most appropriate . 

A patient undergoing extensive testing is usually fearful of the procedures and anxious about the possible test results. The nurse can help relieve fear and anxiety by explaining the tests to be performed, the sensations likely to be experienced, and the patient’s role in the test procedures. The nurse encourages the patient and family to voice their fears about the test results, supports the patient and family throughout the test period, and reinforces and clarifies information conveyed by the physician. The nurse also encourages the patient and family members to communicate and share their concerns and to discuss their questions and concerns with each other. (Medical and Surgical Nursing; Brunner & Suddarth10th Edition)

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Posted in: Brunner,Cancer