Hodgkin’s disease, a neoplastic disorder, is characterized by painless, progressive enlargement of the lymph nodes, spleen, and other lymphoid tissue. The enlargement is caused by a proliferation of lymphocytes, histiocytes, eosinophils, and Reed-Sternberg giant cells, the cells that characterize Hodgkin’s disease; their presence classifies a lymphoma as Hodgkin’s, and their absence classifies a lymphoma as non-Hodgkin’s. Hodgkin’s is a progressive and fatal disease if not treated but is one of the most curable neoplastic diseases with treatment. Hodgkin’s disease has a worldwide incidence of 59,000 cases each year, which is 0.7% of all cancers. It accounts for 26,000 deaths, or 0.5% of all cancer deaths each year. The 1-year survival rate with treatment is 93%, and the 5-year survival rate is 82%. At 15 years, the overall survival rate is 63%.
The cause of Hodgkin’s disease is unknown. Many researchers have suspected an infectious component. Some of the early symptoms include fever, chills, and leukocytosis, as if a viral infection were present. Gene fragments similar to those of a murine leukemia virus have been found in Hodgkin’s tissue. In particular, higher than usual Epstein-Barr antibodies have been found in many Hodgkin’s patients, and a small increase in Hodgkin’s incidence has been found in people who have had the Epstein-Barr–induced disease, infectious mononucleosis. Some people who have reduced immune systems, such as those with AIDS and organ transplant patients, are also at a higher risk for Hodgkin’s disease.
Nursing care plan assessment and physical examination
Many patients present with asymptomatic peripheral adenopathy. Because there are numerous causes for enlarged lymph nodes, it is important to elicit information about recent infections, allergic reactions, and other events. In Hodgkin’s, the nodes tend to be cervical, supraclavicular, and mediastinal. About 40% of patients report fever, night sweats, and recent weight loss, collectively called B symptoms. Less commonly, they may report pruritus during any stage. Because the B symptoms are necessary for staging, it is important to elicit that information in the history.
During advanced phases of the disease, the patient may have edema of the face and neck, weight loss, and jaundice. Palpate all lymph node chains, including the submental, infraclavicular, epitrochlear, iliac, femoral, and popliteal nodes. Involved nodes are characteristically painless, firm, rubbery in consistency (unlike the rock-hard nodes of carcinoma), freely movable, and of varying size. Palpate the liver and spleen, which may be enlarged.
The diagnosis of a neoplastic disorder in young adulthood is a devastating event for the patient and significant others. Rather than pursuing educational goals, job obligations, social interactions, or parenting responsibilities, the young adult is suddenly managing a potentially terminal disease. Although the disease is treatable in most cases, the patient needs to manage short- and long-term complications of therapy that may profoundly alter the patient’s body image. Infertility in young adults after treatment may affect the patient’s view of herself or himself and the long-term potential for the desired role of parenthood.
Nursing care plan primary nursing diagnosis: Risk for infection related to impaired primary and secondary defenses.
Nursing care plan intervention and treatment plan
Treatment begins with accurate classification and staging. Clinical staging is determined by initial biopsy, history, physical examination, and radiologic findings. Pathological staging involves a more extensive surgical assessment of possible sites for spread. Owing to continued improvement in radiologic staging, a staging laparotomy (thorough abdominal exploration, splenectomy, liver biopsy, bone marrow biopsy, and multiple lymph node samplings) is performed infrequently.
In general, radiation is used for early, less extensive disease. A combination of radiation and chemotherapy is used for stages IIB, IIIA, and B. Combination chemotherapy with drugs such as doxorubicin, bleomycin, vinblastin, and dacarbazine (ABUD) is used for stage IV (see Pharmacologic Highlights). External beam radiation is the most effective single agent in the treatment of Hodgkin’s disease and may be given after three to four courses of chemotherapy. Stages I and IIA Hodgkin’s disease are routinely treated with external beam radiation therapy. Mantle therapy (radiation to the chest wall, mediastinum, axilla, and neck—the region known as the mantle field) is done for supradiaphragmatic sites. Radiation-protective shields are used to block irradiation to unaffected areas. These shields are custom fit for each patient, based on his or her physical configurations. Surgery is not used as a treatment modality in Hodgkin’s except in the role of staging. A dietary consultation may be needed to help the patient maintain weight and to help support healing.
If the disease does not respond to standard treatment, bone marrow transplantation may be offered, either as part of a clinical trial or outside of a clinical trial. The patient’s own bone marrow is removed and stored. Then very high doses of chemotherapy, sometimes in combination with radiation therapy, are administered to eradicate the cancer. High doses also destroy bone marrow. The stored marrow is administered intravenously to the patient, and bone marrow cells enter the bloodstream and return to the bone. The transplanted marrow produces new red and white blood cells. In another type of transplant, peripheral blood stem cell transplant (PBSCT), only the stem cells (immature cells from which all blood cells develop) are removed and the rest of the blood is returned to the body. Stem cells are then frozen until they are returned to the patient after treatment is finished.
The primary nursing roles are to maintain comfort, protect the patient from infection, provide teaching and support about the complications of the treatment, and give emotional support. During mantle irradiation, the patient may suffer from a variety of uncomfortable or painful conditions. Dry mouth, loss of taste, dysphagia, nausea, and vomiting can be managed with frequent mouth care. Manage skin irritation and redness. Encourage the patient to avoid applying lotions, perfumes, deodorants, and powder to the treatment area. Explain that the skin must be protected from sunlight and extreme cold. Before starting treatments, arrange for the patient to have a wig, scarf, or hat to cover any hair loss, which occurs primarily at the nape of the neck. Explain to the patient that pneumonitis and hypothyroidism may occur; explain the signs and symptoms of each and when to notify the physician. During inverted-Y irradiation, nausea, vomiting, anorexia, diarrhea, and malaise require nursing management.
If the patient develops bone marrow suppression during hospitalization, make sure that all staff and visitors use good hand-washing techniques. Do not assign a nurse who is caring for infected patients. Encourage staff and visitors with infections to avoid all contact with the patient. If the patient receives chemotherapy, the side effects are equally uncomfortable. In addition to many of the symptoms that occur in response to radiation therapy (gastrointestinal symptoms, oral lesions, hair loss, bone marrow depression), the patient may develop joint pain, fever, fluid retention, and a labile emotional state (euphoria or depression) that need specific interventions
based on their incidence and severity.
The disease presents severe emotional stressors to the patient and her or his significant others. The complexity of the diagnostic and staging process may make the patient feel lost in a crowd of specialists. It is important for the nurse to provide supportive continuity. Patience and repeated explanations are needed. Provide the patient with information about support groups, and refer the patient to either a clinical nurse specialist, support groups associated with the American or Canadian Cancer Society, or counselors.
Nursing care plan and discharge home health care guidelines
Although they are cured of the disease, patients who survive Hodgkin’s disease continue to have immune defects that persist throughout life. Defects include transiently depressed antibody production, decreased polymorphonuclear chemotaxis, decreased antigen-induced T-cell proliferation, and changes in delayed hypersensitivity. Coupled with the sometimes lingering aftereffects of radiation and chemotherapy, the patient needs to maintain infection vigilance even after remission is obtained. Teach the patient lifelong strategies to avoid infection.
Patients may have other complications for up to 25 years after mantle radiation therapy, including hypothyroidism, Graves’ disease, and thyroid cancer. Irradiation can also cause pulmonary and pericardial fibrosis and coronary artery changes, and it may increase the risk for the development of solid tumors such as lung cancer, breast cancer, and others. Explain the presenting symptoms of the disorder, provide written information for the patient, and encourage yearly physicals to maintain follow-up. Because infertility may be a complication of chemotherapy, men may want to think of sperm banking before treatments, although many have sperm dysfunction at diagnosis.