Evidence-Based Nursing Care for Multiple Myeloma Patients

Evidence-Based Nursing Care for Multiple Myeloma Patients Comprised of the blood cells, blood, lymph, and other organs involved in the formation or storage of blood, the hematologic system allows the human body to maintain adequate oxygenation and tissue perfusion (Ignatavicius & Workman, 2010, p. 876). Because every cell, tissue, organ, and system is dependent on blood circulation for survival, hematologic problems involving impaired production, impaired function, or abnormal destruction of blood cells are likely to have wide-reaching effects on the patient's health and wellness (Ignatavicius & Workman, 2010, p. 876). This is especially clear when examining cancers of the hematologic system, including multiple myeloma. A cancer of certain white blood cells in the bone marrow known as plasma cells, “myeloma” refers to a tumor of the bone marrow, and “multiple” refers to more than one area of the bone marrow being affected (Mangan, 2006, p. 64hn1). Because the disease is incurable, and because only 30 percent of patients survive longer than five years after diagnosis, living with multiple myeloma can be difficult for patients and their families (Mangan, 2006, p. 64hn1). As health care providers on the front lines of patient care, nurses must be aware of the multi-system manifestations of multiple myeloma, be able to make the assessments needed to identify and prevent complications related to the disease and its treatment regimen, and be ready to provide patients and their families with knowledge and support. In this paper, the author will first provide a full description of multiple myeloma, including etiology and risk factors, pathophysiology, diagnostic tests, and treatment. This accomplished, the author will apply the stages of the nursing process to nursing care of patients with multiple myeloma, including nursing interventions based on evidence-based practice. The author will focus on the nursing diagnoses Risk for Infection, Risk for Injury, Fatigue, and Knowledge Deficit in describing the nursing care of multiple myeloma patients (Carpenito-Moyet, 2010). In doing so, the author will show that through appropriate use of the nursing process, nurses can improve both the quality of life and overall survival of patients with multiple myeloma.
Description of Issue
Etiology and Risk Factors As previously stated, multiple myeloma is a cancer characterized by the proliferation of the B-lymphocytes known as plasma cells (Ignatavicius & Workman, 2010, p. 915). It is a relatively rare cancer, accounting for approximately one percent of new cancer cases (Faiman, 2007, p. 831). This translates to roughly 19,900 diagnoses, and over 10,000 deaths, per year in the United States (Faiman, 2007, p. 831). Peak incidence of multiple myeloma is in patients between 50 and 70 years of age (Faiman, 2007, p. 831). Although cause is largely unknown, risk factors may include a positive family history, exposure to ionizing radiation, viruses such as human herpes 8, and exposure to herbicides and other occupational chemicals (Faiman, 2007, p. 831). The incidence of multiple myeloma is significantly higher in men than women, and African Americans than Caucasians (Ignatavicius & Workman, 2010, p. 915). Even with ongoing advances in treatment, median survival time after diagnosis remains around three years (Black & Hawks, 2009, p. 2029).
Pathophysiology
Normally, B-lymphocytes play an important role in the body's immune response (Kelly, Meenaghan, & Dowling, 2010, p. 1415). Their function is to become sensitized to a specific antigen and to then produce antibodies that neutralize or destroy that antigen (Kelly et al., 2010, p. 1415). The antibodies produced by plasma cells are known as immunoglobulins, and can be categorized as IgA, IgD, IgE, IgG, and IgM (Kelly et al., 2010, p. 1415). In multiple myeloma, plasma cells become cancerous, infiltrate the bone marrow, and overproduce one of the aforementioned classes of immunoglobulins (Kelly et al., 2010, p. 1415). The overproduced protein is subsequently known as the 'M' protein (Kelly et al., 2010, p. 1415). In 60 percent of patients, immunoglobulin G is the abnormal immunoglobulin produced; in 40 percent of patients, immunoglobulin A is the abnormal immunoglobulin produced (Ignatavicius & Workman, 2010, p. 915). As a consequence of plasma cell infiltration, the bone marrow is no longer able to produce enough red blood cells, white blood cells, or platelets to meet the needs of the body (Ignatavicius & Workman, 2010, p. 915). This leads to manifestations of anemia, leukopenia, and thrombocytopenia (Ignatavicius & Workman, 2010, p. 915). Additionally, when released into the blood, the excess immunoglobulins increase serum protein levels, obstruct blood vessels, and cause ischemia to the kidneys and other vital organs (Ignatavicius & Workman, 2010, p. 915). Furthermore, the cancerous plasma cells overproduce cytokines, the most important of which are interleukin-6 and tumor necrosis factor alpha (Faiman, 2007, p. 833). These cytokines protect cancer cells from apoptosis, contribute to further cancer cell growth, and lead to subsequent bone destruction (Faiman, 2007, p. 833).
Clinical Manifestations The patient with multiple myeloma often presents with vague symptoms of back pain and generalized weakness and fatigue (Faiman, 2006, p. 832). The patient may report frequent infections or unusual bleeding (Black & Hawks, 2009, p. 2029). Other early manifestations of multiple myeloma involve “CRAB” symptoms: elevated serum calcium, renal insufficiency, anemia, and bone lesions (Snively, 2009, p. 13). With regard to renal insufficiency, patients may have diminished renal function related to high serum uric acid and gamma globulin, which lead to renal tubule obstruction and renal failure (Kelly et al., 2010, p. 1417). With regard to bone lesions, 70 percent of patients present with bone pain related to pathologic fractures, most commonly of the pelvis, spine, and ribs (Black & Hawks, 2009, p. 2029). The most common cause of death in patients with multiple myeloma is infection or sepsis related to reduced immune system function, followed by renal failure (Rodriguez et al., 2007, p. 580).
Diagnostic Tests A range of tests are used to diagnose multiple myeloma, including radiographic studies, bone marrow biopsy, and blood and urine examinations (Black & Hawks, 2009, p. 2029). Radiographic studies of the patient often reveal osteolytic lesions, diffuse demineralization, and osteoporosis, particularly of the bones of the skull, sternum, rib cage, and spine (Black & Hawks, 2009, p. 2029). Because of this deterioration, the bones of a multiple myeloma patient are often described as having a “Swiss cheese” appearance (Ignatavicius & Workman, 2010, p. 915). Bone marrow biopsy reveals that 10% or more of the bone marrow has been infiltrated by plasma cells (Ignatavicius & Workman, 2010, p. 915). A CBC usually confirms the presence of anemia, leukopenia, and thrombocytopenia, and a large amount of abnormal immunoglobulins are detected in plasma electrophoresis (Black & Hawks, 2009, p. 2029). The Bence-Jones or myeloma paraprotein, which is composed of incomplete antibodies, appears in a 24-hour urine test, and the serum beta-2-microglobulin level is elevated (Ignatavicius & Workman, 2010, p. 915). Depending on the stage of the disease, renal function tests may reveal elevated serum creatinine and other signs of compromise (Faiman, 2007, 832).
Treatment
The best overall survival rate is seen among patients who are treated with a combination of chemotherapy agents and autologous stem cell transplant (Rodriguez et al., 2007, p. 581). Candidates for bone marrow transplant are often treated with the “VAD” regimen, consisting of the chemotherapy agents vincristine, doxorubicin, and dexamethasone (Black et al., 2009, 2029). These drugs help to reduce the tumor burden and maximize the benefits of the transplant (Ignatavicius & Workman, 2010, p. 915). Increasingly, a number of new therapies, including thalidomide, lenalidomide, and bortezomib are being used to treat multiple myeloma (Mangan, 2006, p. 64hn2).
Relevance to the Nursing Process
Assessment
Because it affects many body systems, the nurse needs to conduct a comprehensive assessment of the patient if multiple myeloma is suspected. The nurse should first consider the patient's age, and ask about past exposure to radiation, occupational chemicals, and other agents known to increase the risk for multiple myeloma (Ignatavicius & Workman, 2010, p. 903). The nurse should take a history of the patient's illnesses during the past six months, which may indicate decreased immune function (Ignatavicius & Workman, 2010, p. 903). The nurse should also take a history of bleeding episodes, and note any reports of ecchymoses, epistaxis, hematuria, and other indications of diminished platelet action (Ignatavicius & Workman, 2010, p. 903). The nurse should discuss the manifestations of anemia with the patient, and determine whether the patient has experienced unusual weakness, fatigue, or unplanned weight loss (Ignatavicius & Workman, 2010, p. 913). The nurse should assess the patient for tachycardia, pallor, slow capillary refill, orthostatic hypotension, and other objective indicators of anemia (Ignatavicius & Workman, 2010, p. 913). The nurse should also be alert for patient complaints of bone pain and if present note its location (Ignatavicius & Workman, 2010, p. 904). Because it is an “unknown cancer” for which there is little public awareness, most patients and their support persons have never heard of multiple myeloma at the time of their diagnosis, and may not even understand that they have just been diagnosed with a form of cancer (Dowling, 2011, p. 42). Furthermore, many patients feel that healthcare professionals are “too busy” to answer questions (Dowling, 2011, p. 42). Thus, in addition to a physical assessment, the nurse must also complete a psychosocial assessment to understand the patient's knowledge of the disease process, feelings regarding his diagnosis, and concerns related to treatment (Ignatavicius & Workman, 2010, p. 904). Nursing assessment is incomplete without addressing the anxiety and fear commonly expressed by patients with multiple myeloma (Dowling, 2011, p. 42).
Diagnosis
Priority nursing diagnoses for the patient with multiple myeloma include Risk for Infection related to neutropenia and decreased immune response; Risk for Injury related to thrombocytopenia and pathologic fractures; Fatigue related to anemia, decreased tissue oxygenation, and increased energy demands; and Knowledge Deficit related to new cancer diagnosis, treatment regimen, and self-care activities needed to prevent complications (Carpenito-Moyet, 2010). While discussion of nursing care will focus on only these nursing diagnoses, many other nursing diagnoses may apply to the patient with multiple myeloma and require subsequent nursing interventions.
Planning
With regard to the priority nursing diagnoses Risk for Infection, Risk for Injury, Fatigue, and Risk for Complications of Renal Dysfunction, the patient with multiple myeloma is expected to remain free from infection, bleeding and pathologic fractures, increased fatigue, and renal complications (Ignatavicius & Workman, 2010, pp. 905-911). With regard to the priority nursing diagnosis Knowledge Deficit, the patient is expected to understand her disease process, course of treatment, and patient actions needed to minimize complications. The nurse should plan to implement neutropenic precautions, bleeding precautions, and fall risk precautions. The nurse should remove environmental hazards that place the patient at risk for injury, help the patient to balance the need for activity with the need for rest, and develop an exercise regimen appropriate for the patient's physical condition. Extensive patient teaching is needed regarding the disease and its management, including the signs and symptoms of hypercalcemia and side effects of chemotherapy agents and other medications.
Implementation
Risk for infection. With regard to the nursing diagnosis Risk for Infection, a literature review of evidence-based practice suggests that strict hand washing with soap and water or alcohol-based agents reduces the incidence of infection in patients with cancer (Zitella et al., 2006, pp. 742-743). Visitors should be taught to wash their hands before and after entering the patient's room, and the nurse should not allow visitors with manifestations of respiratory infection to visit the patient (Zitella et al., 2006, pp. 742-743). Strict, aseptic technique should be used during all procedures (Ignatavicius & Workman, 2010, p. 906). Providing frequent oral care by regularly inspecting and cleaning the patient's mouth reduces the risk of mucositis, a common complication of neutropenia (Zitella et al., 2006, p. 743). As mucositis is also a frequent side effect of chemotherapy agents used in the treatment of multiple myeloma, several studies support the use of ice chips as a prophylaxis during treatment (Zitella et al., 2006, p. 743). There is also strong evidence to support the administration of colony-stimulating factors, prophylactic antibiotics and antifungals, and an annual influenza vaccine to reduce the patient's risk for infection (Zitella et al., 2006, pp. 739-742). While there is only limited evidence to support the use of protective isolation, a diet that restricts unwashed fruits and vegetables and uncooked foods, and restrictions on flowers and plants in the patient's room, these interventions are likely to be effective and should also be implemented as appropriate Zitella et al., 2006, pp. 746-747). Additionally, it is suggested that the nurse should take the patient's vital signs every four hours, frequently assess the patient for signs and symptoms of infection, and monitor the patient's CBC daily (Ignatavicius & Workman, 2010, p. 906). Risk for injury. With regard to the nursing diagnosis Risk for Injury, the nurse should assess the patient for bleeding every four hours, monitor the patient's platelet count and other laboratory values daily, and implement bleeding precautions (Ignatavicius & Workman, 2010, p. 910). The patient should be moved gently, and lift sheets should be used during repositioning (Ignatavicius & Workman, 2010, p. 910). Intramuscular injections and venipunctures should be avoided if possible (Ignatavicius & Workman, 2010, p. 910). If injection or venipuncture is necessary, the nurse should use the smallest-gauge needle possible, apply pressure to the site until bleeding stops, and check any IV sites every two hours for signs of bleeding (Ignatavicius & Workman, 2010, p. 910). The patient's urine and stool should be tested periodically for occult blood (Ignatavicius & Workman, 2010, p. 910). The nurse should avoid taking rectal temperatures and using rectal suppositories and enemas (Ignatavicius & Workman, 2010, p. 910). The nurse should teach the patient about preventing trauma to the mouth by using a soft-bristled toothbrush, avoiding hard foods, and not flossing (Ignatavicius & Workman, 2010, p. 910). The patient should also be taught to use electric razors when shaving, to avoid contact sports, and the importance of wearing shoes when ambulating (Ignatavicius & Workman, 2010, p. 910). In addition to the above interventions, the use of platelet transfusions is strongly supported by the evidence in preventing and managing episodes of bleeding in patients with cancer (Damron et al., 2009, p. 576). It is recommended that ice packs, elevation, direct pressure, and the administration of topical hemostatic agents be used to treat existing bleeding (Damron et al., 2009, p. 580). To prevent injury such as pathologic fractures and spinal cord compression related to skeletal damage, the nurse may administer bisphosphonates such as pamidronate (Aredia) to inhibit the resorption of bone (Faiman, 2007, p. 837). In addition to reducing serum calcium levels, bisphosphonates reduce the incidence of bone pain, pathologic fractures, and osteoporosis, and may make the bone environment more unfavorable to the proliferation of cancer cells (Faiman, 2007, p. 837). Exercise may help to prevent bone loss and subsequent injury (Kelly et al., 2010, p. 1420). The patient should be taught to report changes such as paresthesias and loss of sensation that may indicate spinal cord compression (Devenney & Erickson, 2004, p. 402). Fatigue. With regard to the nursing diagnosis Fatigue, a literature review of evidence-based practice suggest that screening for and managing etiologic factors such as anemia, depression, nausea and vomiting, pain, and sleep disturbance, helping patients to conserve energy by clustering care, teaching patients to prioritize and pace activities, and encouraging relaxation through breathing exercises, yoga, and massage are likely to be effective in managing fatigue (Mitchell, Beck, Hood, Moore, & Tanner, 2006, p. 109). Although the evidence is limited, many experts believe that corticosteroids, eating a balanced diet, and distraction are also beneficial (Mitchell et al., 2006, p. 111). The most strongly supported intervention to manage fatigue is the use of exercise (Mitchell et al., 2006, p. 109). Coleman, Hall-Barrow, Coon, and Stewart (2003) found that multiple myeloma patients who participated in a personalized, home-based exercise program reported improved fatigue, physical fitness, and psychological outlook compared to the control group (p. 529). Appropriate nursing actions may include identifying perceived barriers to exercise, coordinating with a physical therapist to identify exercises that the patient can complete safely, and helping the patient to obtain exercise equipment that is easy to use (Coleman et al., 2003, p. 540). Multiple myeloma patients also benefit from the administration of blood transfusions and colony-stimulating factors such as epoetin alfa (Procrit) as prescribed (Anaissie et al., 2008, p. 60). Knowledge deficit. With regard to the nursing diagnosis Knowledge Deficit, Coon, McBride-Wilson, and Coleman (2006) use the case study of a multiple myeloma patient to document the role of nurses in helping the patient and support persons move through the “dizzying pace” of diagnosis and treatment (p. 825). Nurses should be mindful of the fact that “...patients' lives can depend on how well they absorb and retain the information provided at a time when they are facing a personal crisis (Coon et al., 2006, p. 825). Multiple myeloma patients often feel that the teaching they receive in the hospital setting is inadequate, and feel unprepared to take on the complex responsibilities of self-care and adherence to a medication regimen that are required after discharge (Coon et al., 2006, pp. 825-826). The nurse should provide ongoing patient teaching supplemented with easy-to-follow instructions in both written and picture, timeline, and chart form (Coon et al., 2006, pp. 825-828). Creative solutions to knowledge deficits, such as providing the patient with a medication administration record to use at home and helping a patient to package his drug therapy into easy-to-administer, hourly increments may be indicated (Coon et al., 2006, pp. 827-828). Using the aforementioned strategies, the patient should be taught the signs and symptoms of hypercalcemia and the importance of reporting them immediately (Black & Hawks, 2009, p. 2030). The patient should also be provided with information about the common side effects and potential adverse reactions related to his medications, including the manifestations of peripheral neuropathy and deep vein thrombosis (Snively, 2009, p. 14). To alleviate bone pain, the patient should be taught to take acetaminophen or prescribed opioid analgesics rather than NSAIDs (Kelly et al., 2010, p. 1420). Due to ongoing research and development of new pharmacologic interventions for multiple myeloma, the patient may benefit from referral to clinical trials when possible (Kelly et al., 2010, p. 1418). The nurse may also offer the patient referrals to organizations such as the International Myeloma Foundation, The Multiple Myeloma Research Foundation, and the American Cancer Society for further support (Kelly et al., 2010, p. 1420). In particular, the International Myeloma Foundation provides a helpline, website, support groups, and seminars for patients and their families (Kelly et al., 2010, p. 1420). Lastly, because renal insufficiency occurs in 50 percent of multiple myeloma patients and is a leading cause of mortality, teaching patients about self-care activities that prevent renal compromise is a nursing priority. The nurse should instruct patients about the importance of taking allopurinol (Zyloprim) as prescribed to reduce serum uric acid levels (Kelly et al., 2010, p. 1417). Perhaps most importantly, the nurse should encourage the patient to maintain adequate hydration, usually around 3 to 4 liters of fluid per day (Kelly et al., 2010, p, 1417). Fluids dilute high serum calcium and uric acid levels and prevent the precipitation of excess protein in the renal tubules (Kelly et al., 2010, p. 1417). If the patient is unable to maintain adequate fluid intake related to acute illness or the side effects of treatment, he should be advised to seek medical treatment so that intravenous fluids can be administered (Kelly et al., 2010, p. 1420).
Evaluation
With regard to the nursing diagnosis Risk for Infection, the nursing goal is met if the patient remains free from infection (Ignatavicius & Workman, 2010, p. 905). The patient will have a neutrophil count within normal limits, will remain afebrile, and will remain free from respiratory changes, gastrointestinal changes, integumentary changes, and other changes that may indicate infection (Ignatavicius & Workman, 2010, p. 905). With regard to the nursing diagnosis Risk for Injury, the nursing goal is met if the patient remains free from bleeding (Ignatavicius & Workman, 2010, p. 910). The patient will have a platelet count within normal limits, an absence of frank and occult bleeding, and remain free from pathological fractures (Ignatavicius & Workman, 2010, p. 910). With regard to the nursing diagnosis Fatigue, the nursing goal is met if the patient reports no increase in fatigue (Ignatavicius & Workman, 2010, p. 910). The patient will demonstrate participation in self-care activities, and balance periods of activity with periods of rest (Ignatavicius & Workman, 2010, p. 910). With regard to the nursing diagnosis Risk for Complications of Renal Failure, the patient will consistently take in the recommended amount of fluids, experience no decline in renal function from baseline, and experience no elevation in uric acid level from baseline. With regard to the nursing diagnosis Knowledge Deficit, the nursing goal is met if the patient verbalizes understanding of the disease process, treatment options, and patient actions that decrease the risk for complications of multiple myeloma.
Conclusion
Living with multiple myeloma provides many challenges for patients and their support persons. Nurses play a crucial role in helping patients through the course of diagnosis and treatment, and the nursing interventions discussed in the body of this paper are necessary to maintain function, prevent the many complications of the disease, and provide patients with the best possible quality of life. While the information provided in this paper is a summary of the current best practices regarding the disease, there is ongoing research and development of new pharmacologic and treatments that may provide patients with better outcomes. In particular, new hope for patients may come from the proteasome inhibitor carfilzomib, an investigational drug (Multiple Myeloma Research Foundation, n.d.). While current clinical trials are exclusive to patients with relapsed refractory multiple myeloma, it is likely that the criteria will be expanded to include newly diagnosed and relapsed patients (Multiple Myeloma Research Foundation, n.d.). Additionally, although there are no clinical sites in Washington State currently participating in carfilzomib trials, more sites are expected to be added (Multiple Myeloma Research Foundation, n.d.). Thus, in addition to providing expert care based on the present understanding of the disease, nurses must keep an eye to the future.

References
Anaissie, E., Barlogie, B., Coon, S., Kennedy, R., Lockhart, K., & Stewart, C. (2008). Effects of exercise in combination with epoetin alfa during high-dose chemotherapy and autologous peripheral blood stem cell transplantation for multiple myeloma. Oncology Nursing Forum, 35(3), E53-61.
Black, J. M., & Hawks, J. H. (8th Ed.). (2009). Medical-surgical nursing: clinical management for positive outcomes. St. Louis, MO: Saunders.
Carpenito-Moyet, L. J. (12th Ed.). (2008). Nursing diagnosis: application to clinical practice. Phadelphia, PA: Lippincott.
Coleman, E., Hall-Barrow, J., Coon, S., & Stewart, C. (2003). Facilitating exercise adherence for patients with multiple myeloma. Clinical Journal of Oncology Nursing, 7(5 Part 1), 529.
Coon, S., McBride-Wilson, J., & Coleman, E. (2007). Back to basics: assessment, communication, caring, and follow-up: a lesson from a couple's journey with multiple myeloma. Clinical Journal of Oncology Nursing, 11(6), 825-829.
Damron, B., Brant, J., Belansky, H., Friend, P., Samsonow, S., & Schaal, A. (2009). Putting evidence into practice: prevention and management of bleeding in patients with cancer. Clinical Journal of Oncology Nursing, 13(5), 573-583. doi:10.1188/09.CJON.573-583
Devenney, B., & Erickson, C. (2004). Multiple myeloma: an overview. Clinical Journal of Oncology Nursing, 8(4), 401-405.
Dowling, M., & Kelly, M. (2011). Patients' lived experience of myeloma. Nursing Standard, 25(28), 38-44. Retrieved from EBSCOhost.
Faiman, B. (2007). Clinical updates and nursing considerations for patients with multiple myeloma. Clinical Journal of Oncology Nursing, 11(6), 831-840. Retrieved from EBSCOhost.
Ignatavicius, D. D., & Workman, M. L. (6th Ed.). (2010). Medical-surgical nursing: Patient-centered collaborative care. St. Louis, MO: Saunders.
Kelly, M., Meenaghan, T., & Dowling, M. (2010). Myeloma: making sense of a complex blood cancer. British Journal of Nursing, 19(22), 1415-1421.
Mangan, P. (2006). Teach your patient about multiple myeloma. Nursing2006, 36(4), 64hn1-4.
Mitchell, S., Beck, S., Hood, L., Moore, K., & Tanner, E. (2007). Putting evidence into practice: evidence-based interventions for fatigue during and following cancer and its treatment. Clinical Journal of Oncology Nursing, 11(1), 99.
Multiple Myeloma Research Foundation. (n.d.). Relapsed/refractory patients: Carfilzomib expanded access program. Retrieved from http://www.themmrf.org/living-with-multiple- myeloma/relapsed-refractory-patients/treatment-options/cmap.html
Rodriguez, A., Tariman, J., Enecio, T., & Estrella, S. (2007). The role of high-dose chemotherapy supported by hematopoietic stem cell transplantation in patients with multiple myeloma: implications for nursing. Clinical Journal of Oncology Nursing, 11(4), 579-594.
Snively, A. (2009). Nursing perspectives on managing adverse effects of new regimens for the treatment of multiple myeloma: side effects, mystery, and mayhem. ONS Connect, 24(8), 13-14.
Zitella, L., Friese, C., Hauser, J., Gobel, B., Woolery, M., O'Leary, C., & Andrews, F. (2006). Putting evidence into practice: prevention of infection. Clinical Journal of Oncology Nursing, 10(6), 739.