replace diseased or damaged BM with functioning BM. 

donation from patient's own BM

Pre ctx, rtx

does not require immunosuppressants post transfusion (self)

BMT from all others (except identical twin)

related or unrelated

BMT from identical twin.

Prefer to use other source. 

Bone Marrow,

Peripheral blood,

Cord blood

RN managment 

Pre BMT

Pre-transplant eval

skilled care during total body radiation

assess/treat toxicities

4-10 day conditioning

with infusion- monitor transfusion reaction

engraftment- BMT to bone marrow sites

2-3 weeks (wbc elevates)

5-16 from pbstt

risk death- sepsis or bleeding

Colony stim factors, graft failure, GVHD, VOD, tumor lysis syndrome, ATN, Pulmonary edema, interstitial pneumonia

Acute GVHD

*Acute- before 100 days post BMT

skin, GI tract, Liv

mild to life threatening

*Chronic- 100 days (+) post BMT

skin, liv, oral mucosa, lungs,

sicca syndrome

can affect all organs

30-50% drop in platelets post aphresis.

week to recover

pain x 1 wk

anxiety r/t outcome

guilt r/t failed graft

infection risk w/BMT

infection- impairs immunity  BMS

Risk infection related to ANC

ANC >1500 normal

ANC<1000 moderate

ANC <500 severe

ANC <100 extreme

Risk infection related to ANC

ANC >1500

Norm? mod? severe? or

extreme?

Risk infection related to ANC

ANC<1000

Norm? mod? severe? or

extreme?

Risk infection related to ANC

ANC<500

Norm? mod? severe? or

extreme?

Risk infection related to ANC

ANC<500

Norm? mod? severe? or

extreme?

Nadir- lowest point of blood counts post treatment

when does it occur and resolve

post ctx?

post nitrosurea agents?

* 7-14 days post ctx- resolves in 3-4 wks

* 3-4 wk post nitrosurea agents- resolves in 6-8 wks

pleural effusion

sx?

sx- sob, pleural pain

pleural effusion

diagnostics?

cxr, ct, us, thoracentesis- therapeutic & diagnostic

pleural effusion

treatment ?

ctx, rtx, chest tube, pleurodesis (talc)

pleuroperitoneal shunt =L/T access for drainage

also thoracentesis

septic shock -

 high dose ctx, danger of bacteria, viral, and fungal infections.

sx?

Bp decreased

warm vs cold shock

temp, Bp stable till cold shock sets in

septic shock

collaborative care?

hemodynamic- fluids, blood/blood prod, dopamine, levophed-vasopressors

02 tx

broad spectrum antibiotics (cx 1st!)

remove source- picc line or port

nutrition- GI intact? PPN/TPN

DIC Acute- 2nd to sepsis

accelerated activation of clotting cascade, depletion of clotting factors

active bleeding and clotting

acute or chronic- can be life threatening

(Clots are deposited in microvasculature; impairs circulation, tissue hypoxia and necrosis.  / coag factors are released =risk for hemorrhage)

DIC

collaborative management

treat underlying cause; ctx rtx for ca,   antibiotics for sepsis

blood prod     heparin -controversial

AT3- inhibits thrombin

Amicar- inhibits fibrinolysis

labs-pt, ptt, plt ct, fibrin split prod, D-dimer

pain rx

tumor lysis syndrome

define-

occurs with high dose chemo

pot. fatal release of intracellular contents with lrg cell kill. 

elev K+, Uric, Phos, and decreased ca+

tumor lysis syndrome

affects to labs ?

elev K+,Uric, Phos

decreased ca+

tumor lysis syndrome

neuro symptoms?

renal?

Neuro- altered mental status, seizures, fatigue, weakness, dysrryhthmia,

(death from cardiac arrest)

Renal- Oliguria to Anuria

tumor lysis syndrome

prevention

baseline lab tests

hydration po or iv

loop diuretics- to lower K+

Allopurinol- inhibits formation of nucleic acid to uric acid

Na+ Bicarb-in iv fluid- alk the urine

tumor lysis syndrome

treatment

kayexalate- phos binding gels

dextrose-insulin

calcium gluconate

avoid nephrotoxic rx and foods

cardio support

dialysis

Anaphylaxis

prevention

*premedicate

Benedryl, Decadron, Solucortef, Pepcid, Tylenol

  Anaphylaxis

rx with high risk

Anaphylaxis

Treatment

stop the causative agent

# 1   AIRWAY !

O2        ABCs !!

IV NS rapidly

Notify PCP

Meds PRN- dipenhydramine

solu-medrol, Epinephrine, Pepcid- histamine blocker

supine- to perfuse vital organs

hypercalcemia

ca+

> 11 mg/dl

risk; breast, lung, head, neck, renal ca,

rx; thiazides, hormones

dehydration, renal impairment, hyperparathyroidism

immobilization

hypercalcemia-

what causes it?

ca+ released from the bones-kidneys cant excrete it, bones can't absorb it.

r/t prostaglandin relase and tumors that prod PTH-like substances that promote ca release, excess vitamin use, dehydration, renal impairment, thiazides and hormone tx

hypercalcemia

symptoms

> 11mg/dl

confusion, bone pain, fatigue, weak, impaired reflexes, dysrrhythmias, polyuria & polydypsia, decreased responsiveness, N/V constip, dehydration

hypercalcemia

treatment

fluids     po 2-3 L/day  or 

          IV NS 5-8 L/day

loop diuretics, exercise-bones, ctx, rtx, steroids,

biphosphates- Aredia IV run 2-24 hrs

Zometa- IV run 15 minutes

dialysis (consider) to decrease Ca+

teach family s/sx to look for!! stool soft for const.

SIADH  what is it?

what causes it?

what are the manifestations?

SIADH- r/t ca (lung) antineoplastics and morphine. Uncontrolled release of ADH by the pituitary causing excess Na+ excretion in urine.  The Heart sends out ANF trying to compensate but increases Na+ urine excretion and worsening hyponatremia.

Manifestations: Low Na+ (Urine/blood)

Increased urine osmo

Decreased Bun, creat, alb from dilution

SIADH-

Na+  levels with symptoms

Mild Hyponatremia =

Na+ 125-135 mEq/L -often asymptomatic

SIADH-

Na+  levels with symptoms

Moderate Hyponatremia =

SIADH-

Na+  levels with symptoms

Severe Hyponatremia =

SIADH collaborative management

goal? correct Na+ (hyponatremia)

Fluid restrict- 500-1000 ml/day

(increase na+ to decrease fluid overload)

Rx: Demeclocycline- inhibits ADH action of renal tubules (stim diuersis) also  Urea, lithium

Hypertonic solution- 3-5%(saline) = Na+ replacement

Possible lasix for sev. hyponatremia.

Lyte monitoring & replacement

monitor I&O, daily wts, LOC, Heart sounds, VS, Urine SG, N/V, edema, fatigue, lethargy.

Increased ICP

signs and symptoms

HA, Decreased LOC, N/V, Sz, lethargy, restless, visual disturb

ICP 

Tests ?

Treatment? 

tests: MRI, CT

treatments: steroids, diuretics, anticonvulsants,

Rtx, Ctx to debulk tumor,

surgery, shunt

Spinal Cord Compression

symptoms? What happens?

compression r/t lymphoma, tumor,intervertebral collapse

assoc w/mets to bone (breast, lung, kidney,prostate, myeloma, lymphoma)

pain 97%, muscle weakness or motor loss, sensory loss-touch, pain, temp

Incontinence or retention urine/BMs, inflm, edema, cough sneeze =pain, numb, tingle, loss of positional sense.

Sexual dysfunction

prog dep on severity, & rapid onset  (60% thoracic,  30% lumbosacral,

10% cervical)

Spinal Cord Compression

Tests?

Treatment?

tests: MRI, Myelogram, LP

tx: surg, Rtx-reduce tumor, possibly Ctx w Rtx, Pain managment, corticosteroids-reduce swelling,

Superior Vena Cava Syndrome

define?

what happends?

w/ breast and lung ca  

blood is blocked, can't get back to atria (caused by compression or invasion by tumor, enlarged lymph nodes, or thrombus) Affects Head, neck, arms and thorax.

Red face, Venous distention, Eyes bulging

Leads to Bronchial restriction, laryngeal edema, (not enough blood to brain)  Rtx to debulk tumor mass. 

Superior Vena Cava Syndrome

symptoms?

(SOB)dyspnea- support w O2, airway etc.,

face, hands, neck, chest and vein distention/swelling, cough, HA, irritable, dizzy,chest pain, distended veins of jugular, temporal and arms, increased ICP causing alt Mentation, visual disturbances and HA

Superior Vena Cava Syndrome

Tests?

Treatment?

tests: Cxr, CT, MRI, w/u for primary ca

 treat: underlying cause

Rtx, Ctx. surgery-stent or bypass, remove CVC, ? thrombolytic/coag tx-for intraluminal thrombosis, corticosteroids, cautious diuretics

avoid upper extremity venis & Bp measurement, elev HOB, energy conservation,  I&O's, monitor Ctx & Rtx issues

Infection-

What fever do we report?

Management of infection-

RN action

obtain cultures 1st!

broad spectrum antibiotics

Neutropenic precautions

Teach family s/sx infection

hand hygiene, antipyretics, skin integ, Hematopoietic growth factors

change in mental status

Low Bp

low or high temp

cool clammy skin,

decrease in urine output

dysrhythmias

lyte imbal

abn ABGs

VS Q 15-30 min      neuro assess     I&O and lytes

ABGs and pulse ox     IV fluids     Blood and products

vasopressors     Antibiotics     O2

Thrombocytopenia -

What is nomal plt count?

Bleeding risk associated w/ plt count-

risk

mod

severe/transfuse

<100,000

20,000-50,000

<20,000

<10,000 maj hemorrhages

<100 fungal infections

Ca ;leukemia, prostate, GI, lungs, and chemo Rx

and

Sepsis, hep. failure and anaphylaxsis

Normal lab value:

Bun

Normal lab value:

Creat

Normal lab value:

alb

Normal lab value:

Urine Osmo

Normal lab values:

Urine SG (relates to SIADH)

Normal lab values:

Ca+

Cardiac Tamponade-

what is it?

-accumulation of fld in pericardial space compressing the heart which can't fill during diastole.  heart can't pump (HF), circ. system collapses. 

r/t tumors (lung,Esoph,breast ca.)

Rtx >4000Gy to medistinal area =fibrosis, pericarditis, & resulting tamponade.

Cardiac tamponade-

Manifestations-

tests-

s/sx-

distant heart sounds, gallops, Cardiac dullness, Compensatory tachycardia 

tests- ECG, Chest xray, CT 

s/sx- Bp decreases Narrow pulse pressure, SOB, tachypnea, weak, chest pain, orthopnea, diaphoresis, lethargic, alt LOC,

Neck Vein distention =Kaussmauls,

Pulses Paradoxsis= SBP decrease exceeding 10 mm during inspir/ stronger with expir.

Cardiac tamponade-

treatment-

Pericardial centesis-(fld refills)

Pericardial window w/sclerosing (talc),

Rtx w/antineoplastics possibly -prednisone, diuertics

assess-

VS, pulsus paradoxus, ECG,Heart & Lung sounds, Neck veins,LOC, Resp, skin color & temp (grey/dusky), abg's & lytes

elev HOB, O2, oral hygiene, turn, C&db, Patent IV, Reorient pt.

pulse pressure-

 (r/t cardiac tamponade)

 SBP - DBP

If <30 mm Hg considered significant reduction in CO.

decrease r/t reduced stroke vol, &EF, shock, HF, hypovolemia, obstruction of bld flow during systole (mitral or aortic stenosis)