Textbook of Medical-Surgical Nursing 3e

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Chapter 11

Oncology: Nursing management in cancer care

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

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