NURSING CARE OF THE PATIENT WITH HEMATOLOGIC/NEOPLASTIC DISORDERS

1. NURSING CARE OF THE PATIENT WITH HEMATOLOGIC/NEOPLASTIC DISORDERS Presented by: Mary Lesperance, MSN, ARNP-C

2. LEARNING OBJECTIVES • Define anemia, causation & diagnosis • Define cancer • List types of cancer & understand methods for detection and diagnosis

3. OBJECTIVES (2) Describe classification systems for cancer. Discuss treatment options and and how they are chosen Identify classifications of chemotherapeutic agents and administration

4. OBJECTIVES (3) Explain role of nurse in prevention and detection of cancer Describe complications that can occur Describe nursing management of patient receiving therapy

5. Nursing Responsibility • Importance of knowledge • Education • Support • Care

6. HEMATOLOGY ANEMIAS

7. ANEMIA • Greek: “Without blood” • Qualative or quantative deficiency of hemoglobin in RBC • Carries O2 from lungs-tissues • Causes: • blood loss • blood destruction (hemolysis) • Deficient red blood cell production • Lack of iron in body

8. ANEMIA • Most common ww deficiency disease • WHO 1/3 ww population • Iron deficiency anemia most common hematologic disease of infants and children US & WW • Low iron 2o cow’s milk (iron-poor & interferes with absorption in gut)

9. Effects • Children: Development delays & behavior disturbances (May be irreversible after age 4) • Adults: May be subtle or dramatic • Pica (dirt, paper, wax, ice, hair) • Pallor, weakness, fatigue, general malaise, poor concentration • Severe: body compensation – increased cardiac, palpitations, sweatiness, heart failure (not enough hgb = not enough O2 circulating)

10. S/S R/T ANEMIA • Fatigue • Shortness of breath • Ataxia • Headache • Coldness in hands and feet • Pale Skin • Decreased concentration

11. LABORATORY - Anemia • Hemoglobin (Hgb) • Hematocrit (Hct) • Red blood cell (RBC)* (Micro vs Macro) • Serum ferritin • Serum iron • Total iron-binding capacity (TIBC) • Reticulocytes • Methylmalonic acid (vitamin B 12) • Homocysteine

12. LABORATORY - CBC • Hemoglobin – • Measures 02 capacity of blood • Low levels usually indicate anemia • Lacks specificity to reflect body iron stores • Hematocrit – • % of volume of blood occupied by RBCs • Less accurate than Hgb: • Falsely elevated in hyperglycemia & dehydration • Time & temperature sensitive

13. BIOLOGY - Hgb • Protein in the RBC’s – • Iron-rich • Iron is one of building blocks of Hgb • Polypectide chain • Heme (red) • Iron (blue) • Alpha/beta chains HGB MOLOCULE

14. SERUM IRON • Measures amount of iron in blood • Does not fall until iron stores (serum ferritin) are depleted • Diagnostic value lower • Day to day fluctuations • Increases with ingestion • Decreases due to infection, inflammation, malignancy • Need to look at other values (TIBC)

15. SERUM FERRITIN • Serum Ferritin (one of most useful est. of total iron stores) • Intracellular – stored in tissues • Plasma/Serum – released into blood • High - sign of increased stores, Low usually due to iron deficiency • High can be due to malignancies, infection and/or inflammation, many transfusions

16. TOTAL IRON-BINDING CAPACITY (TIBC) • Measure of amt of iron that transferrin can carry • Increases with iron deficiency (body tries to capture more) • Diagnostic: • High: iron deficiency, normal pregnancy • Low: inflammation, infection, malignant tumors, malnutrition

17. SERUM IRON • Iron (red) stored inside ferritin and absorbed in duodenum • (why slow-release may be ineffective to prevent upset stomach, but slow release won’t be absorbed as well)

18. TRANSFERRINTransfers iron to areas requiring

19. FOLIC ACID + VITAMIN B12 • Folic Acid – DNA synthesis of RBCs • Vitamin B12 – transports folic acid from serum to RBC • B12 Def Folic Def • Methylmalonic acid Elev. Normal • Homocysteine level Normal or Elevated • Elev.

20. SICKLE CELL ANEMIA • Autosomal recessive genetic disease • Protective of malaria – most died in 20’s • High infant death “ogbanjes” – “children who come and go” • 340,000 born each year ww – majority in belt around Med. Sea (Greece, Italy, Saudi, Africa) • Nigeria >100,000/yr – 75% die between 1-5 • US – 85% reach 18; few live past 50 • 1/500 African-American births; 1, 1000-1400 Hispanic (lots of notes in ppt)

21. Sickle cell conditions are inherited from parents in much the same way as blood type, hair color and texture, eye color and other physical traits. The types of hemoglobin a person makes in the red blood cells depend upon what hemoglobin genes the person inherits from his or her parents. Like most genes, hemoglobin genes are inherited in two sets…one from each parent. If one parent has Sickle Cell Anemia and the other is Normal, all of the children will have sickle cell trait. (Most people with sickle cell trait are healthy. If one parent has Sickle Cell Anemia and the other has Sickle Cell Trait, there is a 50% chance (or 1 out of 2) of having a baby with either sickle cell disease or sickle cell trait with each pregnancy. When both parents have Sickle Cell Trait, they have a 25% chance (1 of 4) of having a baby with sickle cell disease with each pregnancy.

22. SICKLE CELL DISEASE • Most common in US: • Hgb SS (sickle cell anemia) • Hgb SC disease • Hgb sickle beta-thalessemia • Causes deoxygenation of heme – hydrophobic interactions – distorting RBC into ‘sickle’ shape – stiff & sticky – form clumps. • See notes on next page)

23. People with sickle cell conditions make a different form of hemoglobin A called hemoglobin S (S stands for sickle). Red blood cells containing mostly hemoglobin S do not live as long as normal red blood cells (normally about 16 days). They also become stiff, distorted in shape and have difficulty passing through the body’s small blood vessels. When sickle-shaped cells block small blood vessels, less blood can reach that part of the body. Tissue that does not receive a normal blood flow eventually becomes damaged. This is what causes the complications of sickle cell disease .

24. SICKLE CELL ANEMIA • Present @ birth – s/s usually after 4 mos. • (testing @ birth, genetic testing) • Pneumonia and infections major cause of death in children with Sickle Cell Anemia • Other – meningitis, influenza, hepatitis • S/S vary from mild to severe • Sickle Cell trait (AS) is an inherited condition in which both hemoglobin A and S are produced in the red blood cells, always more A than S. Sickle cell trait is not a type of sickle cell disease. People with sickle cell trait are generally healthy.

25. Complications • Low RBCs • Pain Episodes • Strokes • Increased infections • Leg ulcers • Bone damage • Jaundice • Gallstones • (pain is most common side effect) • Delayed growth • Lung blockage • Kidney damage • Priapism • Sequestration in liver or spleen • Eye damage

26. The sickle cells also block the flow of blood through vessels resulting in lung tissue damage (acute chest syndrome), pain episodes (arms, legs, chest and abdomen), stroke and priapism (painful prolonged erection). It also causes damage to most organs including the spleen, kidneys and liver. Damage to the spleen makes sickle cell disease patients, especially young children, easily overwhelmed by certain bacterial infections

27. S/S R/T Pain • Chronic or Acute/Sudden Pain – • Almost all have painful crisis @ some point • Sickled RBCs “clump” in bloodstream • Major cause of hospitalization, E.D. visits • Pain for hours to days

28. Prevention/Relief of Symptoms • Goals • Relieve pain • Prevent infections (prophylactic pcn) • Prevent eye damage; strokes • Control complications

29. Medications • Hydroxuria • Chemotherapy w/ multiple side effects that go along with chemo: N/V/A, stomatitis, diarrhea, etc. • Improved growth • Prevents organ damage • Decreases need for transfusions • Hydroxyurea – • Improved growth, prevents organ damage, decreases need for transfusions, (side effects)

30. FINAL THOUGHTS • EDUCATION (Professionals & patients) • Increased fluids • Self-Care (keep as active as possible, not being active is worse for contractures) • PAIN CONTROL • PAIN IS WHAT THE PATIENT SAYS IT IS!!! • Minorities – mainly – causes issues

31. Cancer Statistics 2006 A Presentation From the American Cancer Society

32. US Mortality, 2003 1. Heart Diseases 685,089 28.0 2. Cancer556,902 22.7 3. Cerebrovascular diseases 157,689 6.4 4. Chronic respiratory diseases 126,382 5.2 5. Accidents 109,277 4.5 6. Diabetes mellitus 74,219 3.0 7. Influenza and pneumonia 65,163 2.7 8. Alzheimer disease 63,457 2.6 Rank Cause of Death # deaths % deaths Source: US Mortality Public Use Data Tape 2003, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006.

33. 2008 Estimated US Cancer Cases* Men720,280 Women679,510 Prostate 25% Lung & bronchus 15% Colon & rectum 10% Urinary bladder 7% Melanoma of skin 5% Non-Hodgkin 5% lymphoma Kidney 4% Oral cavity 3% Leukemia 3% Pancreas 3% All Other Sites 20% • 26% Breast • 14% Lung & bronchus • 10% Colon & rectum • 6% Uterine corpus • 4% Non-Hodgkin lymphoma • 4% Melanoma of skin • 4% Thyroid • 3% Ovary • 3% Kidney • 3% Leukemia • 23% All Other Sites *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, Cancer Facts & Figures 2007..

34. Now we will turn our attention to the number of new cancers anticipated in the US this year. It is estimated that almost 1.4 million new cases of cancer will be diagnosed in 2006. Cancers of the prostate and breast will be the most frequently diagnosed cancers in men and women, respectively, followed by lung and colorectal cancers both in men and in women.

35. 2006 Estimated US Cancer Deaths* Men291,270 Women273,560 Lung & bronchus 31% Colon & rectum 10% Prostate 9% Pancreas 6% Leukemia 4% Liver & intrahepatic 4%bile duct Esophagus 4% Non-Hodgkin 3% lymphoma Urinary bladder 3% Kidney 3% All other sites 23% • 26% Lung & bronchus • 15% Breast • 10% Colon & rectum • 6% Pancreas • 6% Ovary • 4% Leukemia • 3% Non-Hodgkin lymphoma • 3% Uterine • 2% Multiple myeloma • 2% Brain/ONS • 23% All other sites ONS=Other nervous system. Source: American Cancer Society, 2006.

36. Lung cancer is, by far, the most common fatal cancer in men (31%), followed by colon & rectum (10%), and prostate (9%). In women, lung (26%), breast (15%), and colon & rectum (10%) are the leading sites of cancer death.

37. Change in the US Death Rates* by Cause, 1950 & 2003 Rate Per 100,000 1950 2003 HeartDiseases CerebrovascularDiseases Pneumonia/Influenza Cancer * Age-adjusted to 2000 US standard population. Sources: 1950 Mortality Data - CDC/NCHS, NVSS, Mortality Revised. 2003 Mortality Data: US Mortality Public Use Data Tape, 2003, NCHS, Centers for Disease Control and Prevention, 2006

38. Cancer Death Rates*, by Race and Ethnicity, US,1998-2002 *Per 100,000, age-adjusted to the 2000 US standard population. †Hispanic is not mutually exclusive from whites, African Americans, Asian/Pacific Islanders, and American Indians/ Alaska Natives. Source: American Cancer Society, Cancer Facts & Figures 2007.

39. Overall, cancer death rates are higher in men than women in every racial and ethnic group. African American men and women have the highest rates of cancer mortality. Asian and Pacific Islander men and women have the lowest cancer death rates, about half the rate of African American men and women, respectively. Note: Rates for populations other than white and African American may be affected by problems in ascertaining race/ethnicity information from medical records. This is likely to result in reported death rates that are lower than true death rates.

40. Cancer Death Rates* by Sex and Race, US, 1975-2002 Rate Per 100,000 African American men White men African American women White women *Age-adjusted to the 2000 US standard population. Source: Surveillance, Epidemiology, and End Results Program, 1975-2002, Division of Cancer Control and Population Sciences, National Cancer Institute, 2005.

41. Tobacco Use in the US, 1900-2002 Per capita cigarette consumption Male lung cancer death rate Female lung cancer death rate *Age-adjusted to 2000 US standard population. Source: Death rates: US Mortality Public Use Tapes, 1960-2002, US Mortality Volumes, 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2005. Cigarette consumption: US Department of Agriculture, 1900-2002.

42. The last set of slides describes at the prevalence of cancer risk factors, such as tobacco use and physical inactivity, and the prevalence of cancer screening, such as use of mammography. Tobacco use is a major preventable cause of death, particularly from lung cancer. The year 2004 marks the anniversary of the release of the first Surgeon General’s report on Tobacco and Health, which initiated a decline of per capita cigarette smoking in the United States. As a result of the cigarette smoking epidemic, lung cancer death rates showed a steady increase through 1990, then began to decline among men. The lung cancer death rate among US women, who began regular cigarette smoking later than men, continues to increase slightly.

43. Childhood Cancer • #1 cause of death by disease children & adolescents • 12,000 dx In U.S. every year; over 3000 will die from it • One in 300 Americans will develop cancer before age of 20 • Median age of adults – 67 • Median age of children – 6 (NCI)

44. Cancer Incidence & Death Rates* in Children 0-14 Years, 1975-2002 Rate Per 100,000 Incidence Mortality *Age-adjusted to the 2000 Standard population. Source: Surveillance, Epidemiology, and End Results Program, 1975-2002, Division of Cancer Control and Population Sciences, National Cancer Institute, 2005.

45. Trends in Survival, Children 0-14 Years, All Sites Combined1974-2001 Year ofDiagnosis Age 5 - Year Relative Survival Rates * • 1974 - 1976 1995 - 2001 • 1974 - 19761995 - 2001 • 0 - 4 Years • 5 - 9 Years • 1974 - 1976 1995 - 2001 • 10 - 14 Years *5-year relative survival rates, based on follow up of patients through 2002.Source: Surveillance, Epidemiology, and End Results Program, 1975-2002, Division of Cancer Control and Population Sciences, National Cancer Institute, 2005.

46. The 5-year relative survival rate for all three age groups increased significantly between the mid 1970s and late 1990s. For example, the 5-year relative survival rate increased from 55.1% in 1974-76 to 79.2% in 1995-2001 for cases diagnosed among children 10-14 years old.

47. CANCER • Group of >200 diseases • Characterized by uncontrolled and/or unregulated growth of cells • Most feared of all diseases • Often synonymous with death, pain, disfigurement • Second most common cause of death in U.S.

48. Normal Cellular Proliferation • Stem Cell – all cells from fertilized ova • Differentiate (very, very important! Test question) • Predetermined • Mature functioning cell of only that tissue • Stable and orderly progression • Respects boundaries and territory • Degenerates and dies

49. APOPTOSIS • Equilibrium between cell growth and death • Pro-apoptotic vs. anti-apoptotic stimuli • Programmed cell death • Remove old, dead, unwanted

50. MUTATION • Mutation • Single gene theory – clonal evolution/mutation • Genetic and/or environmental and/or virus damages DNA • Age (77% >55) lifelong accumulations of DNA mutations – may be unable to repair all or cell-mediated immunity reduced • Proto-ononcogens – regulate normal processes (passed from prev. generations & may be over/under expressed) • Tumor suppressor genes (p53) may be abnormal (supresses tumors)