Chapter 11
Oncology: Nursing management in cancer care
259
recipient. The transplantation and collection processes are the
same with syngeneic BMT as with allogeneic BMT.
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 eval-
uations to assess the current clinical (physical and psycho
logical) status of the disease. Nutritional assessments, extensive
physical examinations and organ function tests, and psy-
chological evaluations are conducted. Blood investigation
includes assessing past antigen exposure (e.g. to hepatitis virus,
cytomegalovirus, herpes simplex virus, HIV and syphilis). The
patient’s social support systems are also evaluated. Informed
consent and patient education about the procedure and pre-
transplantation 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 regime)
and total body irradiation are administered. The acute toxici-
ties of nausea, diarrhoea, mucositis and haemorrhagic 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
blood oxygen 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. During stem cell reinfusion,
patients may experience adverse reactions to the cryopro-
tectant dimethyl sulfoxide (DMSO) used to preserve the
harvested stem cells. These reactions may include nausea,
vomiting, chills, dyspnoea, cardiac arrhythmias and hypo
tension progressing to cardiac or respiratory arrest (Rodriguez
et al., 2007).
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. A cluster of symptoms
referred to as engraftment syndrome occurs during the neutro-
phil recovery phase in both allogeneic and autologous trans-
plants. Clinical features of this syndrome vary widely but may
include non-infectious fever associated with skin rash, weight
gain, diarrhoea and pulmonary infiltrates, with improvement
noted after the initiation of corticosteroid therapy rather than
antibiotic therapy (Saria & Gosselin-Acomb, 2007). Until
engraftment is well established, patients require support with
blood products and haemopoietic growth factors.
Potential infection may be bacterial, viral, fungal or proto-
zoan in origin. During the first 30 days following transplant,
the patient is most at risk for developing reactivations of viral
infections including herpes simplex, Epstein-Barr, cytomegalo
virus and varicella zoster. Mucosal denudement poses arisk for
Candida
yeast infection locally and systemically. Pulmonary
toxicities offer the opportunity for fungal infections such as
Aspergillus
. Renal complications arise from the nephrotoxic
longer), the new bone marrow becomes functional and begins
producing red blood cells, WBCs, and platelets (Rodriguez et
al., 2007; Saria & Gosselin-Acomb, 2007).
Before engraftment, patients are at a high risk for infection,
sepsis and bleeding. Side effects of the high-dose chemother-
apy and total body irradiation can be acute and chronic. Acute
side effects include alopecia, haemorrhagic cystitis, nausea,
vomiting, diarrhoea and severe stomatitis. Chronic side effects
include sterility, pulmonary dysfunction, cardiac dysfunction
and liver disease.
Patients receive immunosuppressant drugs, such as cyclo
sporine, tacrolimus (FK 506), or azathioprine (Imuran), to
prevent
graft-versus-host disease (GVHD)
. In allogeneic
transplant recipients, GVHD occurs when the T lymphocytes
from the transplanted donor marrow become activated and
mount an immune response against the recipient’s tissues
(skin, gastrointestinal tract, liver). T lymphocytes respond in
this manner because they view the recipient’s tissue as ‘foreign’,
immunologically differing from what they recognise as ‘self’ in
the donor. GVHD may occur acutely or chronically. Clinical
manifestations of acute GVHD include diffuse rash progressing
to blistering and desquamation similar to second-degree burns;
mucosal shedding with subsequent diarrhoea that may exceed
2 litres per day; and biliary stasis with abdominal pain, hepato-
megaly, and elevated liver enzymes progressing to obstructive
jaundice. GVHD accounts for approximately 10% of all BMT
deaths (Saria & Gosselin-Acomb, 2007).
The first 100 days or so after allogeneic transplantation
are crucial for BMT patients until the immune system and
blood-making capacity (haematopoiesis) have recovered suffi-
ciently to prevent infection and haemorrhage. Most acute side
effects, such as nausea, vomiting and mucositis, also resolve
in the initial 100 days after transplantation. Patients are also
at risk for development of venous occlusive disease (VOD), a
vascular injury to the liver from the high-dose chemotherapy
occurring in the first 100 days or so after BMT. VOD can lead
to acute liver failure and death (Saria & Gosselin-Acomb,
2007).
Autologous BMT is considered for patients with disease of
the bone marrow who do not have a suitable donor for alloge-
neic BMT and for patients who have healthy bone marrow but
require bone marrow ablative doses of chemotherapy to cure
an aggressive malignancy. Stem cells are collected from the
patient and preserved for reinfusion and, if necessary, treated
to kill any malignant cells within the marrow. The patient is
treated with ablative chemotherapy and, possibly, total body
irradiation to eradicate any remaining tumour. The stem cells
are then reinfused and engrafted. Until engraftment occurs in
the bone marrow sites of the body, the patient is at high risk
for infection, sepsis and bleeding. Acute and chronic toxicities
from chemotherapy and radiation therapy may be severe. The
risk of VOD is also present after an autologous transplant. No
immunosuppressant medications are necessary after autolo-
gous BMT because the patient did not receive foreign tissue.
A disadvantage of autologous transplantation is the risk that
viable tumour cells may remain in the bone marrow despite
conditioning regimes (high-dose chemotherapy).
Syngeneic BMT is the least common type of transplantation
because it requires an identical sibling for harvest. Syngeneic
transplantations result in fewer complications and no marrow
rejection because the donor is an identical tissue match to the
