Multiple myeloma: Nursing

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Introduction0:00–0:16

. Multiple myeloma is a type of blood cancer that's characterized by a proliferation of abnormal plasma cells, a type of white blood cell that normally produces antibodies that help us fight infections.
First, let's take a look at the physiology of bone marrow and plasma cells. The main function of bone marrow is to transform hematopoietic stem cells into all types of blood cells, like red blood cells and white blood cells.

Physiology0:16–1:08

Plasma cells develop from a type of white blood cell called B lymphocytes or B cells and are specialized in producing antibodies, also called immunoglobulins that fight infections.
Now, the exact cause of multiple myeloma is unknown, but it's likely due to a combination of environmental and genetic factors, including a family history of multiple myeloma, immunosuppression, advanced age, and environmental exposures to certain toxins like benzene, organic solvents, and petrochemicals.
OK, now let's focus on the pathology of multiple myeloma, which starts with an increased production of abnormal plasma cells called myeloma cells in the bone marrow.

Causes & risk factors1:08–1:57

These cells produce defective antibodies called M proteins, which are ineffective at fighting off infections. But as these M proteins accumulate in the circulation, they can make the blood unusually thick.
This can result in a condition called hyperviscosity syndrome, characterized by sluggish circulation in vital organs like the brain, lungs, eyes, and kidneys.
In addition, the light chain portion of the M proteins called Bentz-Jones proteins can accumulate in the kidneys, causing renal tubular obstruction and even renal failure.
To make things worse, the myeloma cells accumulate in the bone marrow and crowd out other blood cells like red blood cells, white blood cells, and platelets, leading to pancytopenia.
At the same time, these myeloma cells cause bone destruction by producing factors that disrupt the bone remodeling process.

Pathology1:57–3:18

Cells that normally breakdown bone called osteoclasts are activated, and cells that build new bone called osteoblasts are inhibited.
This leads to the formation of lytic bone lesions, which are areas of bone destruction. Now, keep in mind that multiple myeloma typically progresses slowly through stages.
The starting point is a condition called monoclonal gammopathy of undetermined significance, or MGUS. This is a pre-malignant asymptomatic condition characterized by low levels of M proteins in the blood and few myeloma cells in the bone marrow.
After that, some patients can experience an intermediate stage called smoldering multiple myeloma or SMM for short, where there are an increased number of M proteins circulating in the blood and myeloma cells in the bone marrow, but there's no evidence of damage to the kidneys or bones.
Patients with SMM can then go on to develop multiple myeloma, and the rate of progression will typically vary between patients.
Now, let's switch gears and look at the clinical manifestations of multiple myeloma. An easy way to remember the most common myeloma defining clinical manifestations is the acronym CRAB, where C stands for calcium elevation, R stands for renal impairment, A stands for anemia, and B stands for bone disease.

Clinical manifestations3:18–4:46

So as bone breaks down, calcium is released into the blood, which can manifest as signs and symptoms of hypercalcemia, including anorexia, confusion, constipation, polyuria, or even cardiac arrhythmias.
Then as Bentz Jones proteins accumulate in the kidneys, renal impairment can manifest as fatigue, weakness, loss of appetite, fluid retention, and edema.
As a consequence of pancytopenia, patients can present with symptoms like fatigue due to anemia, as well as frequent infections due to neutropenia or easy bruising due to thrombocytopenia.
Finally, as bone destruction progresses to osteopenia and osteoporosis, patients can experience skeletal pain, which often affects the lumbar spine, pelvis, and ribs, as well as bone fractures.
Sometimes, as vertebrae are destroyed, there can be a decrease in height and signs of spinal cord compression like back pain, weakness, numbness, and a feeling of burning or tingling in the extremities.
On imaging, lytic bone lesions may also be present. As far as laboratory test results go, common findings include hypercalcemia, a decreased hemoglobin level, and a high level of M proteins.

Diagnosis4:46–5:56

As the kidneys are affected, the serum creatinine level increases, and the urinalysis shows the presence of Bentz-Jones proteins.
Other possible clinical manifestations include a triad of findings related to hyperviscosity syndrome. These include spontaneous bleeding commonly from the nose, gums, and eyes due to impaired platelet function and microvascular damage from engorged small blood vessels, visual disturbances such as blurry vision or vision loss from the affected retinal veins.
And neurological findings like headache, confusion, or problems with movement and balance, which are a consequence of reduced cerebral blood flow.
Now, the diagnosis of multiple myeloma starts with the patient's history and physical assessment. To confirm the diagnosis, there should be an excessive amount of myeloma cells detected by bone marrow biopsy or a tumor of abnormal plasma cells outside the bone marrow called a plasma cytoma.
In addition, there must be at least one myeloma defining clinical manifestation, such as those included in the CRAB acronym.

Treatment5:56–6:15

Although there's no cure for multiple myeloma, the ultimate goal is to reduce the number of myeloma cells and slow down the disease progression.
This can be done using corticosteroids, chemotherapy, radiotherapy, immunotherapy, or autologous stem cell transplant. Other treatments are focused on managing the disease and its symptoms.

Treatment6:15–6:58

Medications to inhibit bone breakdown like the bisphosphonate zoledronic acid can help prevent bone fractures, reduce serum calcium levels, and help with bone pain.
Pancytopenia can be treated with hematopoietic agents like recombinant human erythropoietin and blood and platelet transfusions.
Finally, surgery could be necessary for complications like fractures or spinal cord compression. All right, let's discuss the management of care for a patient with multiple myeloma.
Your goals of care include providing supportive care for disease-related symptoms. Now, as you provide care, keep in mind that your patient is at a higher risk of developing fractures.

Management and care6:58–10:50

So begin by instituting fall precautions and provide skeletal support when you're assisting them with position changes or ambulating.
Next, perform a pain assessment to determine the location, quality, severity and timing of the pain, as well as any factor that provokes or relieves their pain.
Administer the prescribed analgesic as needed, as well as the prescribed bisphosphonate to help slow bone damage and reduce bone pain.
Report to the healthcare provider if your patient has symptoms of a vertebral compression fracture, which includes back pain, paresthesia, or altered reflexes, or signs of lumbar vertebral involvement, including weakness in the legs and bowel or bladder incontinence.
Then assist your patient into a stable position and prepare them for further evaluation and possible therapeutic radiotherapy or vertebroplasty as indicated.
Next, review your patient's serum calcium level. Report if the serum calcium is elevated or if your assessments reveal confusion, lethargy, anorexia, nausea, or muscle weakness.
And administer the prescribed IV isotonic saline and corticosteroids. Be sure to also monitor their fluid balance and renal function tests and report indications of renal tubular damage, including increased serum creatinine, elevated urinary albumin, decreased GFR, and reduced creatinine clearance, as well as changes in urinary output.
Then adjust the IV flow rate and administer diuretics as prescribed and continue to monitor their renal function closely.
Also check for infection by monitoring your patient's temperature and CBC and assessing common sites of infection, including their respiratory system and urinary tract.
Report to the healthcare provider if your assessments include a decreasing neutrophil count, fever, dysuria, sputum production, or chest tightness.
Collect cultures of blood and urine and administer the prescribed antibiotics. Then review your patient's hemoglobin and hematocrit and check for signs of anemia.
Report to the healthcare provider if your patient is experiencing symptoms like tachycardia or shortness of breath. If a blood transfusion is required, administer leukocyte reduced packed red blood cells.
Finally, if your patient is undergoing an autologous stem cell transplant, begin induction therapy with the prescribed chemotherapeutic regimen.
Administer the prescribed thromboprophylaxis and monitor your patient closely for chemotherapy-related toxicities, including dermatologic, gastrointestinal, and cardiac toxicities, as well as peripheral neuropathy, fatigue, and venous thromboembolism.
OK, let's move on to patient and family teaching. Begin by explaining how multiple myeloma is a type of cancer that affects the cells that produce antibodies.
Then review the plan of care as well as their prescribed medications, instructing them to take each medication exactly as directed.
Lastly, remind them to keep all of their appointments for chemotherapy, radiation, and follow-up visits with their healthcare provider and encourage them to join a local multiple myeloma support group.
Next, teach them about how they can care for themselves at home to manage symptoms of multiple myeloma. Remind them that their bones can be more prone to fracture and to avoid falls by removing tripping hazards and ensuring they always have good lighting around the house.
Encourage them to stay as active in their daily activities as possible, to engage in activities like short walks, but to avoid vigorous activity or activities that cause pain, and to avoid lifting anything heavier than 10 lbs or 4.5 kg.

General client and family teaching10:50–13:45

Instruct them to contact their healthcare provider right away if they experience an increase in bone pain, especially if they have sudden severe back pain.
Also teach them how the disease and its treatments can damage their kidneys. Teach them to be sure to drink enough fluids to keep their urine a pale yellow color and stress the importance of avoiding NSAIDs, which can impair kidney function.
Instruct them to contact their healthcare provider right away if they have problems like decreased urine output, if they notice blood in their urine, or if they have swelling in their body, especially in their lower extremities.
Remind your patient that they're at increased risk for infection, so review precautions they can take to prevent infection, such as practicing good hand hygiene, avoiding crowds or contact with people who are sick, and taking their prophylactic anti-infective medications as prescribed.
Instruct them to contact their healthcare provider right away if they develop symptoms such as a fever, cough, or painful urination.
Finally Teach your patient to seek medical attention right away if they develop symptoms like shortness of breath, confusion, slurred speech, numbness or weakness of their extremities, or depression.
Alright, as a quick recap, multiple myeloma is a type of blood cancer that's characterized by a proliferation of abnormal plasma cells called myeloma cells in the bone marrow.
Although the cause is unknown, it's likely due to a combination of environmental and genetic factors, including a family history of multiple myeloma, immunosuppression, advanced age, and environmental exposures to certain toxins.
Multiple myeloma defining manifestations can be remembered with the acronym CRAB, where C stands for calcium elevation, R stands for renal impairment, A stands for anemia, and B stands for bone disease.
Diagnosis is accomplished through bone marrow biopsy, imaging, and laboratory test results. Treatment is aimed at reducing the number of myeloma cells, slowing disease progression, and managing symptoms.
Management of care centers around providing supportive care for disease-related symptoms, while patient and family teaching involves learning about the condition and its treatment, self-care at home, and when to contact their healthcare provider or seek immediate medical

Review13:45–13:26