Notes
Description
- Is a malignant lymphoma of the reticuloendothelial system that results in an accumulation of dysfunctional, immature lymphoid-derived cells.
- The disease generally spreads by lymphatic channels, involving lymph nodes, spleen, and ultimately (through the bloodstream) to extra lymphatic sites, such as gastrointestinal tract, bone marrow, skin, upper air passages, and other organs.
- It is most common in patient ages 20 to 40 and in those older than age 60.
- It’s cause is unknown.
Causes/ Risk Factors
The cause of Hodgkin’s disease is unknown. Many researchers have suspected an infectious component. Some of the early symptoms include fever, chills, and leukocytosis, as if a viral infection were present. Gene fragments similar to those of a murine leukemia virus have been found in Hodgkin’s tissue. In particular, higher than usual Epstein-Barr antibodies have been found in many Hodgkin’s patients, and a small increase in Hodgkin’s incidence has been found in people who have had the Epstein-Barr–induced disease, infectious mononucleosis. Some people who have reduced immune systems, such as those with AIDS and organ transplant patients, are also at a higher risk for Hodgkin’s disease.
Assessment:
- Fatigue, fever, chills, night sweats, painless swelling of lymph nodes (generally unilateral), pruritus, weight loss.
- Wide variety of symptoms may occur if there is pulmonary involvement, superior vena cava obstruction, hepatic or bone involvement, and involvement of other structures.
Diagnostic Evaluation:
- Lymph node biopsy detects characteristic Reed-sternberg giant cell, helping to confirm diagnosis.
- Complete blood count and bone marrow aspiration and biopsy determine whether there is bone marrow involvement.
- X-rays, CT scan, and MRI detect deep nodal involvement.
- Lymphangiogram detects size and location of deep nodes involved, including abdominal nodes, which may not be readily seen by CT scan.
- Liver function test and liver biopsy determine hepatic involvement.
- Gallium-67 detects areas of active disease; determines aggressiveness of disease.
- Surgical staging (laparotomy with splenectomy, liver biopsy, multiple lymph node biopsies) may be done in selected patients.
Primary Nursing Diagnosis
- Risk for infection related to impaired primary and secondary defenses
Pharmacologic Interventions:
- Chemotherapy may be used in combination with radiation.
- Initial treatment often begins with a specific four-drug regimen known as MOPP (Mustargen, Oncovin, procarbazine, and prednisone).
- Three or four drugs may be given in intermittent or cyclical courses, with periods of treatment to allow recovery from toxicities.
Medical Management
- Chemotherapy followed by radiation therapy is used in early-stage disease
- Combination chemotherapy alone is now the standard treatment for more advanced disease.
- When Hodgkin’s does recur, the use of high doses of chemotherapeutic medications, followed by autologous bone marrow or stem-cell transplantation, can be very effective.
Surgical Interventions:
- Autologous or allogeneic bone marrows or stem cell transplantation.
Nursing Interventions:
- To protect the skin receiving radiation, avoid rubbing, powders, deodorants, lotions, or ointments (unless prescribed) or application of heat or cold.
- Encourage patient to keep clean and dry, and to bathe the area affected by radiation gently with tepid water and mild soap.
- Encourage wearing loose-fitting clothes and to protect skin from exposure to sun, chlorine, and temperature extremes.
- To protect oral and gastro-intestinal tract mucous membranes, encourage frequent, small meals, using bland and soft diet at mild temperatures.
- Teach the patients to avoid irritants such as alcohol, tobacco, spices, and extremely hot or cold foods.
- Administer or teach self-administration of pain medication or antiemetic before eating or drinking, if needed.
- Encourage mouth care at least twice per day and after meals using a soft toothbrush or toothete and mild mouth rinse.
- Assess for ulcers, plaques, or discharge that may be indicative of superimposed infection.
- For diarrhea, switch to low-residue diet and administer anti-diarrheals as ordered.
- Teach patient about risk of infection. Advice patient to monitor temperature and report any fever or other sign of infection promptly.
- Explain to patient that radiation therapy may cause sterility.
Documentation Guidelines
- Response to staging: Emotional and physical response to diagnostic testing, healing of incisions,signs of ineffective coping,response to diagnosis,ability to participate in planning treatment options,response of significant others
- Response to treatment:Effects of chemotherapy or radiation therapy,or both; response to treatment of symptoms,presence of complications (weight loss,infection,skin irritation)
- Emotional state:Effectiveness of coping, presence of depression, interest in group support or counseling,referrals mad
Discharge and Home Healthcare Guidelines
Although they are cured of the disease,patients who survive Hodgkin’s disease continue to have immune defects that persist throughout life. Defects include transiently depressed antibody production, decreased polymorphonuclear chemotaxis, decreased antigen-induced T-cell proliferation,and changes in delayed hypersensitivity. Coupled with the sometimes lingering aftereffects of radiation and chemotherapy, the patient needs to maintain infection vigilance even after remission is obtained. Teach the patient lifelong strategies to avoid infection. Patients may have other complications for up to 25 years after mantle radiation therapy, including hypothyroidism, Graves’disease, and thyroid cancer. Irradiation can also cause pulmonary and pericardial fibrosis and coronary artery changes,and it may increase the risk for the development of solid tumors such as lung cancer,breast cancer,and others. Explain the presenting symptoms of the disorder,provide written information for the patient,and encourage yearly physicals to maintain follow-up. Because infertility may be a complication of chemotherapy, men may want to think of sperm banking before treatments, although many have sperm dysfunction at diagnosis.
Sources:
Nursingcrib.com
Marilyn Sawyer Sommers, RN, PhD, FAAN , Susan A. Johnson, RN, PhD, Theresa A. Beery, PhD, RN , DISEASES AND DISORDERS A Nursing Therapeutics Manual, 2007 3rd ed
Handbook for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 11th ed.
Exam
Nursing Care Plan
Lymphoma Nursing Care Plan
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
- 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.
Nursing Intervensions
- Let the patient describe problem in own words.
- Rationale: Provides more accurate picture of patient experience with which to develop plan of care.
- Know the importance of sex to individual, partner and patient’s motivation for change.
- Rationale: 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.
- Weigh knowledge of patient and SO regarding sexual function and effects of current situation and condition.
- Rationale: Helps analyze areas of concern, misconception, and actual problems related to therapy side effects.
- Identify preexisting and current stress factors that may be affecting the relationship.
- Rationale: Patient may be concerned about other issues, such as job, financial, and illness-related problems.
- Determine specific pathophysiology, illness, surgery or trauma involved and impact on (perception of) individual.
- Rationale: Patient’s perception of the individual effects of this illness is crucial to planning interventions that will be appropriate to those affected (patient and family).
- Assist with treatment of underlying condition.
- Rationale: As illness is treated and patient can see improvement, hope is restored and patient can begin to look to the future.
- Provide factual information.
- Rationale: Promotes trust in caregivers.
- Encourage and accept expressions of concern, anger, grief, fear.
- Rationale: Helps patient identify feelings and begin to deal with them.
- Encourage patient to share thoughts and concerns with partner and to clarify values and impact of condition on relationship.
- Rationale: Helps couple begin to deal with issues that can strengthen or weaken relationship.
- Refer to appropriate community resources and support groups (CanSurmount).
- Rationale: 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 patient and family.
- Provide written material and bibliotherapy Internet sites, other resources appropriate to age and situation.
- Rationale: Reinforces information patient has received.
- Refer to psychiatric clinical nurse specialist and professional sexual therapist as indicated.
- Rationale: May need additional in-depth assistance to resolve existing problems.
Nursing Diagnosis
- Risk for Ineffective Airway Clearance
- Risk for Ineffective Breathing Pattern
Risk factors may include
- 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. Existence of signs and symptoms establishes an actual nursing diagnosis.
Desired Outcomes
- Maintain a normal/effective respiratory pattern, free of dyspnea, cyanosis, or other signs of respiratory distress.
Nursing Interventions
- Assess and monitor respiratory rate, depth, rhythm. Note reports of dyspnea and use of accessory muscles, nasal flaring, altered chest excursion.
- Rationale: Changes (such as tachypnea, dyspnea, use of accessory muscles) may indicate progression of respiratory involvement and compromise requiring prompt intervention.
- Place patient in position of comfort, usually with head of bed elevated or sitting upright leaning forward (weight supported on arms), feet dangling.
- Rationale: Maximizes lung expansion, decreases work of breathing, and reduces risk of aspiration.
- Reposition and assist with turning periodically.
- Rationale: Promotes aeration of all lung segments and mobilizes secretions.
- Instruct and assist with deep-breathing techniques, pursed-lip or abdominal diaphragmatic breathing if indicated.
- Rationale: Helps promote gas diffusion and expansion of small airways. Provides patient with some control over respiration, helping to reduce anxiety.
- Monitor and evaluate skin color, noting pallor, development of cyanosis (particularly in nailbeds, ear lobes, and lips).
- Rationale: Proliferation of WBCs can reduce oxygen-carrying capacity of the blood, leading to hypoxemia.
- Assess respiratory response to activity. Note reports of dyspnea or ”air hunger,” increased fatigue. Schedule rest periods between activities.
- Rationale: Decreased cellular oxygenation reduces activity tolerance. Rest reduces oxygen demands and minimizes fatigue and dyspnea.
- Identify and encourage energy-saving techniques (rest periods before and after meals, use of shower chair, sitting for care).
- Rationale: Aids in reducing fatigue and dyspnea, and conserves energy for cellular regeneration and respiratory function.
- Promote bedrest and provide care as indicated during acute and prolonged exacerbation.
- Rationale: Worsening respiratory involvement and hypoxia may necessitate cessation of activity to prevent more serious respiratory compromise.
- Encourage expression of feelings. Acknowledge reality of situation and normality of feelings.
- Rationale: Anxiety increases oxygen demand, and hypoxemia potentiates respiratory distress and cardiac symptoms, which in turn escalates anxiety.
- Provide calm, quiet environment.
- Rationale: Promotes relaxation, conserving energy and reducing oxygen demand.
- Observe for neck vein distension, headache, dizziness, periorbital and facial edema, dyspnea, and stridor.
- Rationale: Non-Hodgkin’s patients are at risk for superior vena cava syndrome, which may result in tracheal deviation and airway obstruction, representing an oncologic emergency.
- Provide support to family and caregivers. Encourage open expression of feelings.
- Rationale: Development of this complication is very frightening for patient and family because it may indicate end-stage of disease process and approaching death, especially in the hospice setting. Keeping family informed may diminish their anxiety and minimize transmission to patient.
- Provide supplemental oxygen.
- Rationale: Maximizes oxygen available for circulatory uptake; aids in reducing hypoxemia.
- Monitor laboratory studies (ABGs, oximetry).
- Rationale: Measures adequacy of respiratory function and effectiveness of therapy.
- Administer analgesics and tranquilizers as indicated.
- Rationale: Reducing physiological responses to pain and anxiety decreases oxygen demands and may limit respiratory compromise.
- Assist with respiratory treatments or adjuncts, (IPPB, incentive spirometer) if appropriate.
- Rationale: Promotes maximal aeration of all lung segments, preventing atelectasis.
- Assist with intubation and mechanical ventilation.
- Rationale: May be necessary to support respiratory function until airway edema is resolved in acutely ill hospitalized patient.
- Prepare for emergency radiation therapy when indicated.
- Rationale: Treatment of choice for superior vena cava syndrome.
Nursing Diagnosis
Deficient Knowledge
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
- Verbalize understanding of condition, prognosis, and potential complications.
- Identify relationship of signs/symptoms to disease process.
- Initiate necessary lifestyle changes.
Nursing Interventions
- Discuss potential complications relative to specific therapeutic regimen.
- Rationale: Possible side effects and long-term physical complications of radiation (direct or indirect) and some chemotherapy agents include pneumonitis, hypothyroidism, pericarditis, cardiomyopathy.
- Emphasize need for ongoing medical follow-up.
- Rationale: Following treatment, there is increased risk of secondary malignancies (thyroid, myeloid leukemia, non-Hodgkin’s lymphoma) in addition to other complications listed. Note: Yearly Pap smears are recommended for female patients because Hodgkin’s cells may be found on the cervix.
- Identify signs and symptoms requiring further evaluation, such as cough, fever, chills, malaise, dyspnea (pneumonitis); weight gain, slow pulse, decreased energy level, intolerance to cold (hypothyroidism); moderate fever, chest pain, dry cough, dyspnea, rapid pulse (pericarditis); dyspnea, fatigue, chest pain, dizziness/syncope (cardiomyopathy).
- Rationale: Prompt intervention can limit progression of complication, reduce debilitating effects.
- Recommend regular exercise in moderation, with adequate rest. Discuss energy conservation techniques.
- 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 patient’s ability to perform ADLs.
- Review infection prevention measures and signs and symptoms requiring further evaluation.
- Rationale: Condition is associated with a complex deficiency in cellular immunity both before and after therapy. Note: Herpes zoster is a common occurrence.
- Determine financial needs and concerns. Identify community resources, vocational services.
- Rationale: Although survival rates are relatively good, patients often have limitations in physical activities and employment because of dyspnea, chronic fatigue, and difficulties in concentration or memory. Presence of the disease can also impact patient’s ability to work or qualify for bank loans or obtain insurance.
Other Possible Nursing Care Plans
- Fatigue—decreased metabolic energy production, overwhelming psychological or emotional demands, states of discomfort, altered body chemistry, e.g., chemotherapy.
- Family Processes, interrupted—situational crisis (illness, disabling/expensive treatments).
