Question

C.O. is a 43-year-old woman who noted a nonpruritic nodular rash on her neck and chest about 6 weeks ago. The rash became generalized, spreading to her head, abdomen, and arms, and was accompanied by polyarticular joint pain and back pain. About 2 weeks ago, she experienced three episodes of epistaxis in 1 day. Over the past week, her gums became swollen and tender and she was severely fatigued. Because of the progression of symptoms, she sought medical attention. Lab work was done, and C.O. was directly admitted to the hematology/oncology unit under the care of a hematologist for diagnostic evaluation. Skin biopsy showed cutaneous leukemic infiltrates, and bone marrow biopsy showed moderately hypercellular marrow and collections of monoblasts. Her lumbar puncture specimen was free of blast cells. The final diagnosis was acute myeloblastic leukemia.

C.O. is to begin remission induction therapy with cytarabine 100 mg/m2/day as a continuous infusion for 7 days and idarubicin 12 mg/m2/day IV push for 3 days. She is scheduled in angiography for placement of a triple-lumen subclavian catheter before beginning her therapy.

Laboratory Test Results

Complete Blood Count (CBC)

White blood cells (WBCs) 39,000/mm3 (39 x 109/L)

Monocytes 64%

Lymphocytes 15%

Neutrophils 4%

Blasts 17%

Hemoglobin (Hgb) 10.4 g/dL (104 g/L)

Hematocrit (Hct) 28.7%

Platelets 49,000/mm3 (49 x 109/L)

CASE STUDY PROGRESS

On the ninth day of continuous infusion of chemotherapy, the UAP reports C.O.’s vital signs to you.

Vital Signs

BP 110/54 mm Hg

Heart rate 115 beats/min

Respiratory rate 26 breaths/min

Temperature 101.6° F (38.7° C)

CASE STUDY PROGRESS

Your assessment findings are unremarkable and you notify the intern on call of C.O.’s vital signs. After evaluating C.O., the orders shown in the chart are written.

Physician’s Orders

Blood cultures now × 2 sites

CBC with differential now

Acetaminophen suppository 650 mg q4-6h prn

Imipenem/cilastatin sodium 500 mg IV piggyback q8h

Notify hematologist for temp over 100.0° F (37.8° C)

Laboratory Test Values

WBCs 1200/mm3 (1.2 x 109/L)

Monocytes 25%

Lymphocytes 65%

Neutrophils 5%

Blasts 5%

Bands 0%

Hgb 6.8 g/dL (68 g/L)

Hct 21.3%

Platelets 17,000/mm3 (17 x 109/L)

CASE STUDY PROGRESS

With continued blood product support and antibiotic coverage, C.O. is able to complete 14 days of therapy and a bone marrow biopsy shows she is in complete remission. HLA typing has been done on all her siblings. Her oldest brother is a perfect HLA match and has agreed to donate bone marrow. C.O. is being discharged with plans to readmit her to the bone marrow transplant unit within the next few weeks.

15. What type of isolation will C.O. need? Outline the guidelines for maintaining this type of isolation.

16. Undergoing a bone marrow transplant is challenging. Describe how you would provide emotional support to C.O. and her family.

17. Name 3 complications C.O. will be at risk for after the transplant.

18. Describe graft-versus-host disease.

19. True or false. If the transplanted cells do not engraft, C.O. will die unless another transplant is tried and successful. Defend your response.

Answer 1

15) C.O need a protective isolation or reverse isolation.Reverse isolation is used to protect the person with low immunity from contracting infections.

* Guidelines for reverse or protective isolation-

# Room should be properly cleaned and well ventilated

# Visitors are not allowed or restricted.

# People including health care members who enter the patient's room should perform hand washing and use hand sanitisers before and after entering the room .

# Wear mask and Personal protective equipments like gown ,cap etc before entering the room.PPE should be kept sterile and available outside the room.

# Any one who is sick and I'll are not allowed to enter and visit the client.

# Do not bring objects and materials from outside which is not sterilized , such as fresh flowers, bouquets etc,this may carry microorganisms.

# Instrumentals and objects used for the client should be sterile.

16) Emotional support for C.O and family

* Physical and psychological preparation is very important in bone marrow transplantation ,because it is a complex procedure which need continuous care and support.

* Explain the process of transplantation and care after the procedure in simple and understanding language.

* Arrange councelling sessions .

* Client and family should be educated on post operative management ,continuing treatment ,possible complications like Graft Versus Host Disease,prevention of infection,etc.

* Prepare them emotionally by clearing all their concerns and doubts.

* Encourage them to ventilate and express their feelings.

* Show other client and family who successfully recovered after transplantation.

* Develop a trusting relationship with client and family.

17) Three complications C.O will be at risk after transplantation are-

A) Infections like mucositis,stomatitis,cystitis and othe systemic infections due to immunosuppression.

B) Host Versus Graft Disease- occurs when the transplanted donor marrow becomes activated and produce an Immune response against recipient tissues like skin,liver etc because the new T -lymohocytes consider the recipient's tissues as foreign body.

C) Venous Occlusive Disease( VOD) - due to destruction of small blood vessels causing vascular injury to the liver due to high dose of chemotherapy.

18) Graft Versus Host Disease - It is commonly associated with bone marrow transplantation and stem cell transplantation. Once the grafted bone marrow becomes functional they produce red blood cells ,white blood cells and platelets. GVHD occurs when the T lymphocytes from the transplanted donor marrow become activated and recognize the recipient's tissues as foreign body.

* Symptoms include skin rashes or redness on the skin, itching,nausea, vomiting,diarrhea,yellowish discoloration of skin and eyes etc.

* Proper HLA cross matching is done to prevent this before transplantation and immunosupressents are given after transplantation.

19) True, failure of the engraftment is possible after transplantation and a second transplant from the same donor or another donor is performed usually.

* When the transplant is not successful the C.O can develop severe systemic infections and death can occur ,because the persona Immune system is completely failed and not able to protect the body from infections.