Cardiac Status of a Patient - Assignment Example

Myelofibrosis Part Two   Contents Introduction This paper concerns the proper nursing treatment of Mr. Spring, who has had a recent splenectomy in order to treat a case of myelofibrosis. This paper will first identify the risks of the treatment and disease state of Mr. Spring, and how these risks can be mitigated. This paper will then provide five nursing diagnoses related to the patient, and provide interventions and rationales for each of these diagnoses. The diagnoses will be prioritized in order of importance and need for Mr. Spring. Finally, there will be a discussion of Mr. Spring’s cardiac status. In particular, this paper will focus on how his compromised cardiac function can affect his case, and how it should be dealt with. Risks for the Patient Mr. Spring’s age and compromised cardiac status, plus the longer-term nature of his myelofibrotic symptoms, can increase Mr. Spring’s danger of future morbidity or mortality as compared to a younger patient with a healthier circulatory function. Since Mr. Spring has survived the surgery, he has already overcome one of the biggest causes of deaths—perioperative mortality due to extensive bleeding. In a Mayo study of 223 serial patients, it was found that 20 out of 223, or 9%, died during or shortly after the operation (Tefferi 2000). For the most part, those patients who died suffered from thrombocytopenia. In many cases where the patient survived, ongoing thrombocytopenia was a continuing concern. A secondary concern was a returning nonhypercellular bone marrow, which also limited post-splenectomy survival time. Those two factors contributed to a mean survival time after operation of only 27 months. The most common symptoms were: Constitutional symptoms, 67% Transfusion-dependent anemia, 23% Portal hypertension, 50% In addition, patients suffered from an enlarged liver and marked increase in the number of platelets (16 and 22% respectively). Another study, performed in Brazil, found that some patients had a symptomatic recurrence of their disease (Petroianu 1996). A study performed in France at the CNRS found a similar mortality rate to the Mayo study (8.4%) on a smaller sample population (n=71) (Barosi, et al. 1993). In this case, morbidity at 40% was quite high but unpredictable. As at Mayo, the figures were very similar for new thrombotic or hemorrhagic complications (16.9%). Although the splenectomy is generally recommended for patients over the age of 65, there are significant downsides to the surgery. In addition to losing the beneficial functions of the spleen, the patient also runs a higher risk of blast formation over a longer period of time, rising in one study from a relative risk of 2.2 at 4 years to 14.3 at 12 years (G. A. Barosi 1998) (Shayuni 1999) (Li 2001). Mr. Spring’s prognosis may be partly aided by his good laboratory results before and after the splenectomy. A follow-up study which researched prognostic factors for patients with splenomegaly and myelofibrosis who undertook a splenectomy found that those patients who have better results in hemoglobin levels, WBC counts and fewer chromosomal abnormalities had a better chance of long-term survival than those who did not exhibit these results (G. Barosi 1999). Another study published more recently found that those patients who were 60 and under at the time they were treated with a splenectomy all survived for the 15-year period of the study (Chim 2005). Additional complications from complex abdominal surgery include adhesions. The sequelae can range from pain to retroversion of some organs, including the small intestine and stomach (Rowe 2003). Mr. Spring’s prognosis was not known shortly after his surgery, other than that he did not die during and shortly after the operation. The laboratory results three years later demonstrated that Mr. Spring was essentially symptom- and myelofibrosis-free, but this was not known at the time. Treatment Options for Mr. Spring The primary concerns, as revealed through the above literature review, are the consequences of a compromised clotting and a secondary concern about compromised immune defenses. According to The Clinical Journal of Oncology Nursing, the signs and symptoms of thrombocytopenia-induced sequelae include bleeding in the mucosal, cutaneous and from the surgical scar itself. The first nursing option is to insure that Mr. Spring is inspected on a regular basis to insure that he is not undergoing asymptomatic bleeding. The primary diagnostic indications of uncontrolled bleeding danger include Purpura, including confluent petechiae Ecchymosis, or a bleeding under the skin (leading to bruising) Mucosal bleeding, including in the mouth, throwing up blood, or sclera hemorrhages (Baldwin 2003) If any of these systems is seen, it can be a sign of asymptomatic bleeding, either from the surgical site within the abdomen, or other parts of the body. The nurse should regularly check for bleeding on the head, petechiae in the mouth, swollen lymph nodes and sclera hemorrhage. Cranial bleeding can be a concern with a patient of Mr. Spring’s age, and diagnosis is difficult. The nurse should remain vigilant for any signs of changes in mental status and stroke-like symptoms. Enlarged Liver The nurse should also be conscious of the risk of an enlarged liver of lymphadenopathy. Enlarged and/or tender spots can indicate that the patient is undergoing co-morbid events that may be worthy of informing the on-duty hematologist or oncologist. The doctor can then order a series of tests to determine if there is deterioration in the patient’s status. These tests will include the specific liver enzymes, such as SGT and SGOT, as well as more general markers for cell destruction, such as myoglobin. If the patient is in pain, there are several palliatives which can be used. NSAID’s can help with general swelling, but should not be considered in case of thrombocytopenia, in which case the patient’s potential bleeding problems could be exacerbated by taking substances which control clotting. Steroids can be used to reduce swelling, but the healthcare professional should be careful about not compromising the patient’s immune status. In this case, a careful monitoring of the patient’s white blood cell count as part of a generalized CBC will be important. Some of the older remedies still apply in the case of an enlarged liver. Nitrogen mustards have been used for decades, and may be a helpful pain reliever (Kamofsky 1948). Some treatments which have had success with biliary cirrhosis may also be helpful. In the case of extreme liver swelling, methotrexate may be given, either alone or in combination with colchicines or ursodiol (Kaplan 1997). Treating Potential Recurrence The literature review covered above demonstrates a ca. 16% recurrence rate of myelofibrosis for all patients in two centers, with a greater likelihood of recurrence after age 60 and/or with specific laboratory values. For patients who are suffering from possible recurring myelofibrosis, there may be some newer options available. Specific work on treatment of early secondary myelofibrosis has been done with IVG (in-vitro gamma globulin), which seems to have had an effect in a patient with recurring symptoms (Aharon 1997). In this particular case, the patient had early secondary myelofibrosis with systemic lupus as the primary diagnosis. The administration of large doses of IVG appeared to reverse the symptoms of myelofibrosis, although a longer follow-up would be required to establish its long-term success. In addition, stem cell therapy has been used in conjunction with splenectomy, which has demonstrated in 26 patients some success after a relatively short 2-year period, as illustrated in the following graph: (Li 2001) Bleeding Complications Since thrombocytopenia is a common problem with patients with myelofibrosis, one can expect that a splenectomy might exacerbate the symptoms, particularly perioperatively and in the days after surgery. The body’s natural clotting system is enfeebled by the myelofibrosis in many patients, and the subsequent effect of a major blood-using operation like a splenectomy may enhance the dangers. Major surgery enhances clotting difficulties due to the release of clot-inducing factors from cells damaged through surgery (Valeri 2007). Mr. Winter’s charge nurse should therefore ensure that the patient’s weakened clotting capabilities are taken into account. The registered nurse should be prepared to undertake blood or packed cell transfusion in such patients, and to closely monitor the patient’s ability to clot. In some cases, the consulting hematologist, if available, may have additional recommendations on which elements should be given to the patient, and what needs to be monitored. In addition, the nurse should be fully conversant with components of the clotting cascade and which elements should be monitored in the CBC (Uthman 2006). A low platelet count means that several precautionary measures must be taken, including those that appear minor but can have a major effect on danger to the patient: Use a soft-bristle toothbrush Insure that aspirin and NSAIDs are not taken. In Mr. Spring’s case, the underlying heart disease problem may have led to his physician prescribing daily low-dose aspirin Increasing dietary fiber to prevent constipation Watch out for accidental falls or other accidents which could cause internal bleeding Anemia Concerns Very recent work done at the Mayo Clinic demonstrates a relationship between anemia and primary myelofibrosis (Zimmerman 2007). Those patients who undergo anemia-countering therapies, such as danazol, can actually create a greater problem with an enlarged spleen. The use of ESA’s (anti-anemic agents) was also found to increase spleen size. The principle investigator, who is the chief hematologist at the Mayo Clinic, called for a careful evaluation of such patients. It may be tempting to use red blood cell encouragement in order to counter anemia, particularly when patients and healthcare staff are concerned about the longer-term effects of continued transfusions. The Mayo Clinic retrospective study on 311 patients from 1976 to 2006 showed that leukemic transformation may in fact be elevated with those patients who were treated with erythropoiesis-stimulating agents. Concern about hemorrhagic stroke Ischemic stroke is quite common in the US, but hemorrhagic stroke is also a major concern amongst older patients. Given Mr. Spring’s thrombocytopenic state and general circulatory disease, the RN should be especially vigilant about the potential for hemorrhagic stroke. Stroke is a leading cause of disability. It is estimated that over 50,000 people in the US have a hemorrhagic stroke each year (Franges 1998). The RN should be on the lookout for stroke symptoms, including mental lapses, difficulty speaking or walking, or headaches. If the RN finds that the patient has a possible stroke, he/she should notify the zone attending, while ruling out one or two of the most common potential confounders, such as hypoglycemia (with a finger stick). In addition, the nurse may need to do the following: Place the patient on a cardiac monitor and continuous pulse oximetry Notify MD if not at bedside Place an IV and obtain stat blood work Obtain an immediate finger blood stick for blod sugar ECG (MS onsite health 2005) As with ischemic stroke, hemorrhagic stroke responds most favorably within the first three ‘golden hours.’ (Miller 2004). Immune Status Issues Mr. Spring’s status may be compromised by low white blood cell counts and a particular lack of T-cells which are produced by the spleen. Mr. Winters can be expected to have a low WBC count as a result of the myelofibrosis. When combined with his circulatory problems and general shock-related issues post-surgery, he has a heightened risk of infection. When dealing with Mr. Spring in the hospital, the attending RN must insure that proper antisepsis is observed. She and other members of the staff should handle Mr. Spring while where gloves and, if the white blood cell count is low enough, with a mask as well. The patient should be isolated in his own room, if possible, and those visitors who are allowed should be kept to a minimum, and screened to see if they are suffering from a viral or a bacterial infection. All visitors should avoid direct contact with the patient, which could communicate a disease to him. Mr. Spring may have been given a prophylactic antibiotic after his surgery, but that should not lead the RN or the patient to a false sense of security. Patients with compromised immune systems can be quite susceptible to bacterial infection even if they are taking antibiotics. Part of the reason is that antibiotics do not deal with all the targeted infectious bacteria. Another reason is that some nosocomial infectious organisms are particularly resistant to first- or second-generation antibiotics, including strains of MRSA which are resistant to all but Vancomycin. No antibiotic will ensure that Mr. Spring is safe from viral infection. Since most viruses are labile, proper hand-washing, wearing gloves, and not allowing skin-to-skin contact with the patient should help to reduce the danger of viral transmission. Gastrontestinal Problems Mr. Spring may suffer from additional heart problems which could be related to his myelofibrosis. A study which was published in the Scandinavian Journal of Gastroenterology found that there may be clinically significant portal hypertension (Wiest 2004). If Mr. Spring’s continued enlarged liver and associated elevated liver enzymes continue, one may need to consider the placement of a transjugular intrahepatic stent (TIPS), which could help to relieve the hepatic pressure and return the size and liver cell destruction to more normal levels. It is necessary for the nurse and attending physician to pay close attention to swelling in the abdomen as well as to lab chemistry results: TIPS may be considered as rescue management for refractory ascites secondary to portal hypertension, but caution in respect to the presence and/or development of peritoneal or other ectopic haematopoesis has to be taken. Underlying Heart Condition Mr. Spring’s underlying heart disease may be helped by some aspects of his myelofibrosis and subsequent splenectomy. Although the perioperative morbidity and mortality may have been increased by the compromised circulatory system, the resulting thrombocytopenia may help as a preventative for future ischemic events, as Mr. Spring has a ‘natural’ heart-protective reduction in his platelet level. Some of the drugs which Mr. Spring is taking for his heart disease may have an adverse impact on his symptoms and the underlying myelofibrosis. Each of those elements needs to be reviewed separately for a fit with his condition. For example, if he is taking a statin, the resulting challenge to the liver (in addition to liver implication in the myelofibrosis, plus liver involvement due to the splenectomy) may mean that the common side-effect of liver damage may be enhanced by the taking of a statin. There may be an idiopathic danger from halting statin therapy, however. For this reason, it may be important to consult with the patient’s cardiologist. The sudden cessation of statins may lead to additional plaque formation (Senior 2005). (Tolmie 2006). As mentioned earlier, if Mr. Spring is taking low-dose aspirin for his heart, he may have to stop until his clotting values improve (they were low just after the operation, and continued to be very low even three years after his splenectomy). The reason is that aspirin, even at low doses, can exacerbate Mr. Spring’s potential bleeding problems. The third area to watch is exercise. If Mr. Spring has, on the advice of his cardiologist, undertaken an exercise program, he should be encouraged to engage in low- or non-impact activities, such as walking. This would be in preference to running or contact sports (not likely for a man his age and with his reduced energy level). Even walking must be monitored to insure that Mr. Spring does not fall and create internal bleeding injuries. Conclusion Mr. Spring was able to undergo a difficult operation with a 10% perioperative mortality rate for ‘all comers,’ and a significant co-morbidity rate which appears to be around 40% for all patients. His relatively advanced age (>65) worsens his outlook as compared to younger splenectomy patients, and rules out the use of stem cells as a longer-term solution. His underlying heart disease can pose some treatment complications, particularly when related to medicines that he may be taking in order to improve his heart condition. The fact that Mr. Spring is relatively well three years after his splenectomy speaks to his general state of health, and the fact the nurses and other attending healthcare staff were vigilant. Any complex syndrome like myelofibrosis can lead to a series of secondary problems, even if only 1/6th of those patients who receive a splenectomy have a return of symptoms. 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