Multiple myeloma

BY MEENAKSHI KAUSHIK, PGIMS, ROHTAK.

1. MULTIPLE MYELOMA:--- Multiple myeloma ia a malignant disease of the most mature form of B lymphocytes, the plasma cell. It is not classified as a LYMPHOMA. Plasma cell secrete immunoglobulins , protein necessary for antibody production to fight infection.

2. Plasma cells:-- Plasma cell: A type of white blood cell that produces and secretes antibodies. A plasma cell is a fully differentiated, mature lymphocyte in the B cell lineage. As with most cell types, plasma cells can mutate to give rise to  cancer . Plasma cell malignancies include plasmacytoma ,  multiple myeloma , Waldenstrom macroglobulinemia , and plasma cell  leukemia . Also known as plasmac

3. Incidence usually occurs after 40 years of age. Male : female is 2:1. More common in americans . Median survival rate is 3 to 5 years. Death usually results due to infection.

4. ETIOLOGY:-- The exact causes is UNKNOWN-- There are many prediction regarding the etiology of multiple myeloma , these include— Chronic inflammation. Chronic hypersensitivity reaction. Viral disease. Radiation exposure.

5. PATHOPHYSIOLOGY:-- The disease process involves excessive production of plasma cells. Plasma cells are activated plasma B cells, which produces immunoglobulins that normallys protect the body . However in multiple myeloma malignancy plasma cells infiltrated the bone marrow and produce abnormal and excessive amount of immunoglobulins .

6. Contd.. Usually IgG , IgA , IgD , IgE immunoglobulins formed. This abnormal immunoglobulin formed as myeloma protein. Furthermore , plasma cells production of excessive and abnormal amount of of cytokins also plays an important role in pathological process of bone destruction.

7. Contd.. As myeloma protein increase normal plasma cells are reduced which furthermore decreases the body’s normal immune response. Ultimately the plasma cell destroyes bone and invades the lymph nodes, spleen and the kidneys.

8. CLINICAL MANIFESTATION:-- The condition develops slowly and insidiously. The patient often does not manifest symptoms until the disease advance at which time Skeletal pain is the major manifestation. Pain in the pelvis, spine, & ribs is particularly common. Osteoporosis develops as myeloma destroyes more bones.

9. Contd.. Vertebra destruction can lead to collapse of vertebra which causes compression of spinal cord, requiring emergencies measures to prevent paraplegia. Loss of bone integrity can cause pathological fracture. Hypercalcium may develop due to loss of calcium.

10. Contd.. Hypercalcium will cause:-- Renal changes such as polyuria , hyperuricemia , and renal failure can also occur. In GI anorexia, excessive thirst, dehydration,constipation . In neuro confusion, altered mental status and coma can occur. There may be anaemia , thrombocytopenia, granulocytopenia all of these are due to replacement of normal bone marrow elements with plasma cells.

11. ASSESSMENT AND DIAGNOSTIC FINDINGS:-- Chief complain of bone or back pain with elevated level of total protein. Elevated monoclonal protein spike in the serum or urine or light chain in the urineis major criterion for diagnosis. X’RAY shows lytic bone lesion. Prescence of anaemia and hypercalcium . Bone marrow biopsy.

12. MANAGEMENT:-- There is NO CURE FOR MULTIPLE MYELOMA.. Even BMT is considered by most authorities to extends remission rather than possible cure. Treatment modalities includes:-- Chemotherapy by cyclophosphamide , melphalan , doxorubicin, vincristine is the primary mode of treatment. Corticosteroids particularly dexamethasone is used.

13. contd.. For pain management:--suitable analgesic is used. Pamidronate for skeletal pain, it reduces the osteoclast activity of bone . Some research believes that pamidronate have activity against myeloma cells themselves. The biological agent alpha interferone has been successful in maintaing remission in selected types of multiple myeloma.

14. CONTD… Radition theraphy :-- Radition theraphy is very useful in strengthening a specific bone lesion or spinal cord compression. It is also useful in reducing bone pain.

15. NURSING MANAGEMENT:-- GOALS:-- Reducing pain. Preventing pathological fracture. Maintaing hydration. Prevention of infection. Monitoring for sign of complication. Educating the patient and family members.

16. Nursing diagnosis:-- Pain related to osteoclasts activities or due to disease progression. Assess the level of pain and for the type of analgesic required. Consult with doctor while formulating pain management plan. Administrate the ordered analgesic. NSAIDS are very useful for mild to moderate type of pain. NSAIDS can also be used with opioid analgesics for severe pain.

17. Contd.. High risk for pathological fracture related to decrease bone mass or increased bone clast activity. Activity restriction. Patient educated regarding this , that he she should not lift more than 2-3 kg. Body mechanics are maintained properly. Braces are usually advised to support spinal columan . Skillful handling of patients during moving and turning. Proper positioning and safety in toilet for aged patients.

18. Contd.. Risk for dehydration related to hypercalcemia and inability to take required fluids. Assess the level of hydration. Increase oral intake if possible if not then administer iv fluids. Maintain intake output charts.

19. Contd.. Risk for infection related to altered immunological function of body. Aseptic technique should be followed in every procedure. Patients should be kept in isolated room if possible and if not then limit the visitors or visitors with any type of infection. Avoid going in crowded or dusty area. Mopping should be done in the room instead of brooming . Strict hand washing. Proper care of any extrenous devices. If patient catheterized then care of the catheter.

20. Contd.. High risk for potential complications Watch for sign of any complication.. It can be renal problem, neurological, GIT, Heamatology . Watch for sign of hypercalcemia , polyuria , anaemia , confusion or altered mental status. Report to physician. Keep patient under close observation. Do as per doctors. Advise.

21. Contd.. Knowledge deficit related to disease process and potential complication. Family and patient is taught about potential complication. Advise regarding careful handling of patients. Maintaing good body mechanics, preventing going into high hill places, on unequal surfaces.