Lymphomas Nursing Management

LYMPHOMAS

Malignant lymphomas are cancers of the lymphoid system and include distinct entities defined by clinical, histologic, immunologic, molecular, and genetic characteristics. Based on histologic characteristics, lymphomas are divided into two major categories: Hodgkin’s disease and non-Hodgkin’s lymphoma (NHL). There are five subtypes of Hodgkin’s disease and about 30 subtypes of NHL. Because there are so many different subtypes of lymphomas, the system used to classify lymphomas is very complicated.

These diseases are staged (I–IV) according to the microscopic appearance of involved lymph nodes and the extent and severity of the disorder. They can be further classified by letters of the alphabet (e.g., A, B) according to symptoms present at the time of diagnosis. And in NHL, subtypes can be called low grade, intermediate, and high grade when discussing clinical behaviors of the disease. Accurate staging is most important in deciding subsequent treatment regimens and prognosis.

Hodgkin’s Disease

The etiology of Hodgkin’s disease is unclear, but indirect evidence indicates a viral cause. Signs and symptoms of Hodgkin’s disease are distinctive—clients present with a slow, insidious, superficial lymphadenopathy with lymph (cervical, supraclavicular, mediastinal) nodes that are firm, rubbery, and freely movable. The disease spreads in a generally predictable manner to contiguous lymph nodes via lymphatic channels.

Because of many histologic subtypes and ongoing biologic, pathologic, and clinical studies, classifying lymphomas is controversial. However, in 1999, the World Health Organization (WHO) suggested a change in the subtyping of Hodgkin’s disease that would assist physicians in selecting treatment protocols.

Treatment for Hodgkin’s disease may include radiation, a combination of radiation and chemotherapy, or chemotherapy alone. The cure rate for newly diagnosed cases is higher than 90%, making Hodgkin’s disease one of the most treatable forms of cancer. Bone marrow transplant or peripheral progenitor (stem) cell transplants with high-dose chemotherapy are recommended for clients who have relapsed/failed primary chemotherapy regimen.

Non-Hodgkin’s Lymphoma

Non-Hodgkin’s lymphoma is a malignancy of the B-lymphocyte and T-lymphocyte cell lines. Abnormal lymphocytes accumulate and form masses in lymph tissue such as the lymph nodes, spleen, or other organs. Malignant lymphocytes travel through the circulation to distant sites. Common extranodal sites include the lungs, liver, gastrointestinal tract, meninges, skin, and bones. Most clients with non-Hodgkin’s lymphoma fall into two broad categories related to their clinical features: the nodular indolent type, and the diffuse, aggressive lymphomas. Malignant lymphocytes accumulate in lymph nodes. If the normal follicular structure of the nodes remains intact, the lymphoma is called follicular or nodular. When malignant cells destroy the follicles, the lymphoma is considered diffuse. For treatment purposes, they may be separated into two categories: low-grade lymphoma and aggressive lymphoma (which includes intermediate-grade and high-grade lymphomas).

Treatment for non-Hodgkin’s lymphomas includes watching and waiting, radiation, chemotherapy (usually multiple combinations of antineoplastic agents), monoclonal antibodies (rituximab [Rituxan]), peripheral progenitor (stem) cell transplant, or bone marrow transplant. With or without treatment, low-grade lymphomas can transform into a more aggressive lymphoma, or the tumor replaces the hematopoietic and lymphoid tissue, which leads to multiple systemic dysfunction and death. Intermediate- and high-grade lymphomas tend to be more responsive to treatment.

Care Setting

Acute inpatient care on a medical unit for initial evaluation and treatment, and then at the community level. This plan of care addresses potential complications that may be encountered in acute care or hospice settings.

Related Concerns

Anemias (iron deficiency, pernicious, aplastic, hemolytic)

Cancer

Leukemias

Psychosocial aspects of care

Sepsis/septicemia

Spinal cord injury (acute rehabilitative phase)

Transplantation considerations (postoperative and lifelong) ·

Upper gastrointestinal/esophageal bleeding

Client Assessment Database

Activity/Rest

May report: Fatigue, weakness, or general malaise

Loss of productivity and decreased exercise tolerance

Excessive sleepiness

May exhibit: Diminished strength, slumping of the shoulders, slow walk, and other cues indicative of fatigue

Night sweats

Circulation

May report: Palpitations, angina/chest pain

May exhibit: Tachycardia, dysrhythmias

Cyanosis and edema of the face and neck or right arm (superior vena cava syndrome—obstruction of venous drainage from enlarged lymph nodes is a rare occurrence)

Scleral icterus and a generalized jaundice related to liver damage and consequent obstruction of bile ducts by enlarged lymph nodes (may be a late sign)

Pallor (anemia), diaphoresis, night sweats

Ego Integrity

May report: Increased stress; e.g., school, job, family

Fear related to diagnosis and possibility of dying

Concerns about diagnostic testing and treatment modalities (chemotherapy, radiation therapy)

Financial concerns: Hospital costs, treatment expenses, fear of losing job-related benefits because of lost time from work

Relationship status: Fear and anxiety related to being a burden on family/SO

May exhibit: Varied behaviors; e.g., angry, withdrawn, passive

Elimination

May report: Changes in characteristics of urine and/or stool, vague abdominal pain

History of intestinal obstruction; e.g., intussusception or malabsorption syndrome (infiltration from retroperitoneal lymph nodes)

May exhibit: Abdomen: RUQ tenderness and enlargement on palpation (hepatomegaly); LUQ tenderness and enlargement on palpation (splenomegaly)

Decreased output, dark/concentrated urine, anuria (ureteral obstruction/renal failure)

Bowel and bladder dysfunction (spinal cord compression occurs late)

Food/Fluid

May report: Anorexia/loss of appetite

Dysphagia (pressure on the esophagus)

Recent unexplained weight loss equivalent to 10% or more of body weight in previous 6 months with no attempt at dieting

May exhibit: Edema of the lower extremities (inferior vena cava obstruction from intra-abdominal lymph node enlargement associated with non-Hodgkin’s lymphoma)

Ascites (inferior vena cava obstruction related to intra-abdominal lymph node enlargement)

Neurosensory

May report: Nerve pain (neuralgias) reflecting compression of nerve roots by enlarged lymph nodes in the brachial, lumbar, and sacral plexuses

Muscle weakness, paresthesia

May exhibit: Mental status: Lethargy, withdrawal, general lack of interest in surroundings

Paraplegia (tumor involvement/spinal cord compression from collapse of vertebral body, disc involvement with compression/degeneration, or compromised blood supply to the spinal cord)

Pain/Discomfort

May report: Tenderness/pain over involved lymph nodes; e.g., in or around the mediastinum; chest pain, back pain (vertebral compression); stiff neck; generalized bone pain (lymphomatous bone involvement)

Immediate pain in involved areas following ingestion of alcohol (rare finding in Hodgkin’s disease but may give hints to visceral sites of involvement)

May exhibit: Self-focusing; guarding behaviors

Respiration

May report: Dyspnea on exertion or at rest, chest pain

May exhibit: Dyspnea, tachypnea

Dry, nonproductive cough (hilar lymphadenopathy)

Signs of respiratory distress; e.g., increased respiratory rate and depth, use of accessory muscles, stridor, cyanosis

Hoarseness/laryngeal paralysis (pressure from enlarged nodes on the laryngeal nerve)

Safety

May report: History of frequent/recurrent infections (abnormalities in cellular immunity predispose client to systemic herpes virus infections, tuberculosis (TB), toxoplasmosis, or bacterial infections), mononucleosis (higher risk of Hodgkin’s disease in client with high titers of Epstein-Barr virus), HIV (risk of non-Hodgkin’s lymphoma is 60–100 times higher in these clients compared with the general population)

Administration of immunosuppressive drugs after organ transplantation

History/presence of ulcers/perforation, gastric bleeding

Waxing and waning pattern of lymph node size

Cyclical pattern of evening temperature elevations lasting a few days to weeks (Pel-Ebstein fever) followed by alternate afebrile periods; drenching night sweats without chills

May exhibit: Unexplained, persistent fever higher than 100.4°F (38°C) without symptoms of infection

Asymmetric, painless, yet swollen/enlarged lymph nodes (cervical nodes most commonly involved, left side more than right; then axillary and mediastinal nodes)

Nodes may feel rubbery and hard, discrete and movable

Tonsilar enlargement

Generalized pruritus/urticaria (Hodgkin’s disease)

Patchy areas of loss of melanin pigmentation (vitiligo)

Sexuality

May report: Concern about fertility/pregnancy (although disease does not affect either, treatment does)

Decreased libido

Teaching/Learning

May report: Familial risk factors (higher incidence among families of Hodgkin’s clients than in general population)

History of infections (e.g., HIV, human T-lymphocytic virus type 1 [HTLV-1], Epstein-Barr virus [EBV], Helicobacter pylori may be associated risk factors)

Occupational exposure to pesticides and herbicides or other chemicals; e.g., benzene, creosote, lead, formaldehyde, paint thinner

Discharge plan

considerations: May need assistance with medical therapies/supplies, self-care activities and/or homemaker/maintenance tasks, transportation, shopping

Refer to section at end of plan for post discharge considerations.

Diagnostic Studies

Radiographic studies:

Chest x-ray: May reveal mediastinal or hilar adenopathy, nodular infiltrates, or pleural effusions.

X-rays of thoracic, lumbar vertebrae, proximal extremities, pelvis, or areas of bone tenderness: Determines areas of involvement and assists in staging.

Sanning studies:

Whole lung/ chest computed tomography (CT): Done if hilar adenopathy is present to reveal possible involvement of mediastinal lymph nodes.

Abdominal and pelvic CT scan: May be done to rule out diseased nodes in the abdomen and pelvis and associated organs.

Bone scans: Done to detect bone involvement.

Positron Emission Tomography Scan (PET): Identifies extent of disease and can reveal occult metastases that may not be revealed through other diagnostic studies.

Gallium scan: Not part of routine staging. In client who presents with large mediastinal mass, can distinguish between residual or recurrent disease and persistent scar.

Thoracentesis: May be performed with cytologic studies of pleural fluid.

Abdominal ultrasound:  Evaluates extent of involvement of retroperitoneal lymph nodes.

Lymphangiogram:  Historically a very important diagnostic tool. Seldom done today because of newer scanning technologies.

Biopsies:

Bone marrow: Determines bone marrow involvement, which is seen in advanced stages.

Lymph node: Establishes the diagnosis of lymphoma and cell type involved.

Other tests:

Blood studies may vary from completely normal to marked abnormalities. In stage I, few clients have abnormal blood findings.

CBC:

WBC: Variable, may be normal, decreased, or markedly elevated.

Differential WBC: Neutrophilia, monocytosis, basophilia, and eosinophilia may be found. Complete lymphopenia (late symptom).

RBC and Hb/Hct: Decreased. Anemia is usually present in chronic disease.

Erythrocytes: Stained RBC examination: May demonstrate mild to moderate normocytic, normochromic anemia (hypersplenism).

Platelets: Decreased or may be elevated.

ESR:  Elevated during active stages and indicates inflammatory or malignant disease. Useful to monitor clients in remission and to detect early evidence of recurrence of disease.

Erythrocyte osmotic fragility:

Increased.

Gamma globulin:  Hypergammaglobulinemia is common; may occur in advanced disease.

Serum cryoglobulins:  May be positive with Hodgkin’s disease.

Serum haptoglobin:  May be elevated in Hodgkin’s disease and with cancer of the lung, large intestine, stomach, breast, and liver.

Coombs’ test:  Positive reaction (hemolytic anemia) may occur; however, a negative result usually occurs in advanced disease.

C-reactive protein (CRP) serum titer:  May be positive with Hodgkin’s disease.

Serum iron and TIBC:  Decreased.

Serum copper:  Elevation may be seen in exacerbations.

Serum calcium:  May be elevated when bone is involved.

Serum cytokines e.g. (interleukin-6, interleukin-10, IL-2 receptors):

Correlates with tumor burden, systemic symptoms, and prognosis.

Liver function tests:

Serum alkaline phosphatase: Elevation may indicate either liver or bone involvement.

Serum LDH: Elevated. Important prognostic indicator in non-Hodgkin’s lymphoma, and may indicate a more aggressive cancer.

Kidney function tests:

BUN: May be elevated when kidney involvement is present.

Serum creatinine, bilirubin, antistreptolysin (ASL), creatinine clearance: May be done to detect organ involvement.

Serum uric acid: Elevation related to increased destruction of nucleoproteins and liver and kidney involvement.

Staging laparotomy: Although rarely performed, may be done to obtain specimens of retroperitoneal nodes, of both lobes of the liver, and/or to remove the spleen.

Nursing Priorities

1. Provide physical and psychological support during extensive diagnostic testing and treatment regimen.

2. Prevent complications.

3. Alleviate pain.

4. Provide information about disease process/prognosis and treatment needs.

Discharge Goals

1. Complications prevented/minimized.

2. Dealing with individual situation realistically.

3. Pain relieved/controlled.

4. Disease process/prognosis, possible complications, and therapeutic regimen understood.

5. Plan in place to meet needs after discharge.

Refer to CPs: Cancer and Leukemias for shared nursing diagnoses such as Fear/Anxiety, Self-Esteem, Grieving, Pain, and Nutrition to accomplish corresponding nursing priorities/discharge goals. The nurse is referred to other related cancer care plans for nursing interventions related to treatments such as radiation, chemotherapy, and bone marrow transplant.

NURSING DIAGNOSIS: risk for impaired Gas Exchage

Risk factors may include

Altered oxygen-carrying capacity of blood

Tracheobronchial obstruction: enlarged mediastinal nodes and/or airway edema (Hodgkin’s and non-Hodgkin’s), superior vena cava syndrome (non-Hodgkin’s)

Possibly evidenced by

[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Respiratory Status: Ventilation (NOC)

Maintain a normal/effective respiratory pattern, free of dyspnea, cyanosis, or other signs of respiratory distress; and ABGs WNL.

ACTIONS/INTERVENTIONS Ventilation Assistance (NIC) Independent Assess/monitor respiratory rate, depth, rhythm. Note reports of dyspnea and/or use of accessory muscles, nasal flaring, altered chest excursion. Place client in position of comfort, usually with head of bed elevated or sitting upright leaning forward (weight supported on arms), feet dangling. Reposition and assist with turning periodically. Instruct in/assist with deep-breathing techniques and/or pursed-lip or abdominal diaphragmatic breathing if indicated. Monitor/evaluate skin color, noting pallor, development of cyanosis (particularly in nailbeds, ear lobes, and lips). Assess respiratory response to activity. Note reports of dyspnea/”air hunger,” increased fatigue. Schedule rest periods between activities. Identify/encourage energy-saving techniques; e.g., rest periods before and after meals, use of shower chair, sitting for care. Promote bedrest and provide care as indicated during acute/prolonged exacerbation. Encourage expression of feelings. Acknowledge reality of situation and normality of feelings. Provide calm, quiet environment. Observe for neck vein distention, headache, dizziness, periorbital/facial edema, dyspnea, and stridor. Provide support to family/caregivers. Encourage open expression of feelings. Collaborative Provide supplemental oxygen. Monitor laboratory studies; e.g., ABGs, pulse oximetry. Administer analgesics and tranquilizers as indicated. Assist with respiratory treatments/adjuncts; e.g., IPPB, incentive spirometer if appropriate. Assist with intubation and mechanical ventilation.

RATIONALE     Changes (such as tachypnea, dyspnea, use of accessory muscles) may indicate progression of respiratory involvement/compromise requiring prompt intervention. Maximizes lung expansion, decreases work of breathing, and reduces risk of aspiration. Promotes aeration of all lung segments and mobilizes secretions. Helps promote gas diffusion and expansion of small airways. Provides client with some control over respiration, helping to reduce anxiety. Proliferation of WBCs can reduce oxygen-carrying capacity of the blood, leading to hypoxemia. Decreased cellular oxygenation reduces activity tolerance. Rest reduces oxygen demands and minimizes fatigue and dyspnea. Aids in reducing fatigue and dyspnea, and conserves energy for cellular regeneration and respiratory function. Worsening respiratory involvement/hypoxia may necessitate cessation of activity to prevent more serious respiratory compromise. Anxiety increases oxygen demand, and hypoxemia potentiates respiratory distress/cardiac symptoms, which in turn escalates anxiety. Promotes relaxation, conserving energy and reducing oxygen demand. Non-Hodgkin’s clients are at risk for superior vena cava syndrome, which may result in tracheal deviation and airway obstruction, representing an oncologic emergency. Development of this complication is very frightening for client and family because it may indicate end stage of disease process/approaching death, especially in the hospice setting. Keeping family informed may diminish their anxiety and minimize transmission to client. Maximizes oxygen available for circulatory uptake, aids in reducing hypoxemia. Measures adequacy of respiratory function and effectiveness of therapy. Reducing physiologic responses to pain/anxiety decreases oxygen demands and may limit respiratory compromise. Promotes maximal aeration of all lung segments, preventing atelectasis. May be necessary to support respiratory function until airway edema is resolved in acutely ill hospitalized client.

NURSING DIAGNOSIS: Sexual Dysfunction

May be related to

Altered body structure or function (drugs, surgery, disease process, radiation [loss of sexual desire, disruption of sexual response pattern])

Possibly evidenced by

Verbalization of problem

Actual or perceived limitation imposed by disease and/or therapy

Alteration in relationship with SO

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Sexual Functioning (NOC)

Verbalize understanding of individual reasons for sexual problems.

Identify stressors in lifestyle that may contribute to the dysfunction.

Discuss concerns about body image, sex role, desirability as a sexual partner with partner/SO.

ACTIONS/INTERVENTIONS Sexual Counseling (NIC) Independent Have client describe problem in own words. Determine importance of sex to individual/partner and client’s motivation for change. Assess knowledge of client/SO regarding sexual function and effects of current situation/condition. Identify preexisting and current stress factors that may be affecting the relationship. Determine specific pathophysiology, illness/surgery/trauma involved and impact on (perception of) individual. Assist with treatment of underlying condition. Provide factual information. Encourage and accept expressions of concern, anger, grief, fear. Encourage client to share thoughts/concerns with partner and to clarify values/impact of condition on relationship.

RATIONALE Provides more accurate picture of client experience with which to develop plan. Because lymphomas often affect the relatively young who are in their productive years, these people may be affected more by these problems and may be less knowledgeable about the possibilities of change. Helps identify areas of concern, misconception, and actual problems related to therapy side effects. Client may be concerned about other issues, such as job, financial, and illness-related problems. Client’s perception of the individual effects of this illness is crucial to planning interventions that will be appropriate to those affected (client and family). As illness is treated and client can see improvement, hope is restored and client can begin to look to the future. Promotes trust in caregivers. Helps client identify feelings and begin to deal with them. Helps couple begin to deal with issues that can strengthen or weaken relationship.

Collaborative Refer to appropriate community resources/support groups; e.g., American Cancer Society. Provide written material, Internet sites, and other resources appropriate to age/situation. Refer to psychiatric clinical nurse specialist/professional sexual therapist as indicated.

Provides information about resources that are available to help with individual needs. Meeting with others who are dealing with the effects of devastating illness can help client/family. Reinforces information client has received. May need additional in-depth assistance to resolve existing problems.

 

 

NURSING DIAGNOSIS: deficient Knowledge [Learning Need] regarding disease process, prognosis, treatment regimen, self-care, and discharge needs

May be related to

Lack of exposure/recall

Information misinterpretation

Unfamiliarity with information resources

Cognitive limitations

Possibly evidenced by

Request for information, verbalization of problem, statements reflecting misconceptions

Inaccurate follow-through of instruction, development of preventable complications

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Knowledge: Illness Care (NOC)

Verbalize understanding of condition, prognosis, and potential complications.

Identify relationship of signs/symptoms to disease process.

Initiate necessary lifestyle changes.

ACTIONS/INTERVENTIONS Teaching: Disease Process (NIC) Independent Review with client/SO their understanding of client’s diagnosis and outlook. Review potential treatments client may be considering (e.g., radiation therapy, chemotherapy, biologic therapy, hematopoeietic stem call transplantation [HSCT]; combinations of therapies). Discuss potential complications relative to specific therapeutic regimen. Emphasize need for ongoing medical follow-up. Identify signs/symptoms requiring further evaluation; e.g., cough, fever, chills, malaise, dyspnea, weight gain, slow pulse, decreased energy level, intolerance to cold, moderate fever, chest pain, dry cough, dyspnea, rapid pulse (pericarditis[rare]); dyspnea, fatigue, chest pain, dizziness/syncope (cardiomyopathy [rare]).

RATIONALE Although lymhomas are complex and have intensive treatment regimens, the outlook has improved in recent years. The 5-year survival rate after treatment in both categories of lymphomas has improved significantly, and many people live with lymphoma in remission. May assist client/SO in making informed choices. Although medical treatments are fairly standardized, different doctors have different philosophies and practices. In general, the goal of therapy is remission of the lymphoma, and treatments vary according to the disease process and stage. For example, Hodgkin’s disease stages I-A and II-A are usually treated with radiation therapy or a combination of chemotherapy and radiation. When B symptoms are present, chemotherapy is recommended regardless of stage. Note: Splenectomy is controversial because it may increase the risk of infection and is currently not usually done unless client has clinical manifestations of stage IV disease. Possible side effects/long-term physical complications of radiation (direct or indirect) and some chemotherapy agents include hypothyroidism, thyroid cancer, coronary artery disease, and valvular heart disease. Following treatment, there is increased risk of secondary malignancies (e.g., lung cancer, breast cancer, thyroid, myeloid leukemia, non-Hodgkin’s lymphoma) in addition to other complications listed. After completion of primary therapy, appropriate tests will be repeated to determine efficacy of therapy. Also certain monitoring tests are continued; e.g., thyroid-stimulating hormone (TSH) levels should be monitored yearly starting 8–10 years following radiation therapy (XRT). Yearly Pap smears are recommended for female clients because Hodgkin’s cells may be found on the cervix. Women receiving XRT are at higher risk of developing breast cancer and should receive yearly mammograms starting 8 years following the completion of treatment. Prompt intervention can identify recurrence, or perhaps limit progression of complications, reduce further debilitating effects.

Recommend regular exercise in moderation, with adequate rest. Discuss energy conservation techniques. Determine financial needs/concerns. Identify community resources, vocational services. Recommend/refer to appropriate community resources e.g., support groups, social worker, counselor, pastor; home health assistance, medical equipment/supplies; hospice; Lymphoma Research Foundation, American Cancer Society.

Promotes general well-being. Note: Fatigue is associated with disease process and treatment regimen, as well as developing complications. Therefore, balancing activity with rest enhances client’s ability to perform ADLs. Although survival rates are relatively good, clients often have limitations in physical activities/employment because of dyspnea, chronic fatigue, and difficulties in concentration or memory. Presence of the disease can also impact client’s ability to work or qualify for bank loans or obtain insurance. Client/SO may benefit from many available resources/networks for such help as care assistance, transportation to treatments, sources of financial resources, long-term support/counseling

POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition/presence of complications, personal resources, and life responsibilities)

Fatigue—decreased metabolic energy production, overwhelming psychologic or emotional demands, states of discomfort, altered body chemistry; e.g., chemotherapy.

interrupted Family Processes—situational crisis (illness, disabling/expensive treatments).