HODGKINS DISEASE

A Case Report
Presented to the College of Nursing

In Partial Fulfillment
of the Requirement in
NCM 98: INTENSIVE PRACTICUM

DOROTHY PEARL L. PALABRICA, SN IV

APRIL 2017
 Table of Contents
I. INTRODUCTION ................................................................................................. 2

II. ANATOMY AND PHYSIOLOGY .......................................................................... 5

III. PATHOPHYSIOLOGY...................................................................................... 7

Pathophysiology of Hodgkins Disease: A narrative ................................................... 9

IV. DIAGNOSTIC TESTS..................................................................................... 10

V. INTERVENTIONS.............................................................................................. 14

A. General Nursing Interventions ............................................................................. 14

B. Medical Interventions ........................................................................................... 14

2. Surgical and Special Procedures ......................................................................... 21

VI. NURSING CARE PLANS ............................................................................... 23

REFERENCES ......................................................................................................... 33

1
 I. INTRODUCTION
Hodgkin disease (Hodgkin lymphoma) is a type of lymphoma, a cancer that
starts in white blood cells called lymphocytes. Lymphocytes are part of the immune
system (American Cancer Society, 2016).
Lymphomas are malignant disorders of the reticuloendothelial system that
result in an accumulation of dysfunctional, immature lymphoid-derived cells. They
are classified according to the predominant cell type and by the degree of malignant
cell maturity (eg, well differentiated, poorly differentiated, or undifferentiated).
Hodgkin's lymphoma originates in the lymphoid system and involves predominantly
lymph nodes. There are 2 kinds of lymphomas: a) Hodgkin disease (named after Dr.
Thomas Hodgkin, who first recognized it); b) Non-Hodgkin lymphoma. These types
of lymphomas differ in how they behave, spread, and respond to treatment, so it is
important to tell them apart. Doctors can usually tell the difference between them by
looking at the cancer cells under a microscope or by using sensitive lab tests.
The etiology of Hodgkin lymphoma is unknown. Infectious agents, particularly
EpsteinBarr virus (EBV), may be involved in the pathogenesis (Kppers, Yahalom, &
Josting, 2006). Depending on the study, data show that up to 30% of cases of
classical Hodgkin lymphoma may be positive for EBV proteins (Hodgson et.al, 2015).
In addition, a case control study supports an increased risk of classical Hodgkin
lymphoma after EBV infection, with a risk of approximately 1 in 1000 cases (Al-
Rahawan et. al, 2009). People of any age can be diagnosed with Hodgkin disease,
but it is most common in early adulthood (ages 15 to 40, especially in a persons
20s) and in late adulthood (after age 55) and Hodgkin occurs slightly more often in
males than in females. With regards to family history, brothers and sisters of young
people with this disease have a higher risk for Hodgkin disease. The risk is very high
for an identical twin of a person with Hodgkin disease.
The American Cancer Societys estimates for Hodgkin disease in the United
States for 2017 are: about 8,260 new cases (3,610 in females and 4,650 in males)
and about 1,070 deaths (440 females, 630 males) from this cancer.
Because lymphoid tissue is in many parts of the body, Hodgkin disease can
start almost anywhere. Most often it starts in lymph nodes in the upper part of the
body. The most common sites are in the chest, in the neck, or under the arms.
Hodgkin disease most often spreads through the lymph vessels in a stepwise
fashion from lymph node to lymph node. Rarely, and late in the disease, it can
invade the bloodstream and spread to other parts of the body, including the liver,
lungs, and/or bone marrow.
Different types of Hodgkin disease are classified by how they look under the
microscope. This is important because types of Hodgkin disease may grow and
spread differently and may be treated differently. The 2 main types are: Classic
Hodgkin disease (which has several subtypes) and Nodular lymphocyte predominant
Hodgkin disease.
Classic Hodgkin disease (HD) accounts for about 95% of all cases of Hodgkin
disease in developed countries. The cancer cells in classic HD are called Reed-
Sternberg cells (after the 2 doctors who first described them). These cells are usually
an abnormal type of B lymphocyte. Reed-Sternberg cells are much larger than
normal lymphocytes and also look different from the cells of non-Hodgkin
2
lymphomas and other cancers. The enlarged lymph nodes in classic HD usually
have a small number of Reed-Sternberg cells and a large number of surrounding
normal immune cells. It is mainly these other immune cells that account for the
enlarged lymph nodes (American, Cancer Society, 2016).
Classic HD has 4 subtypes:

Nodular sclerosis Hodgkin disease: This is the most common type of Hodgkin
disease in developed countries, accounting for about 60% to 80% of cases. It
is most common in teens and young adults, but it can occur in people of any
age. It tends to start in lymph nodes in the neck or chest.
Mixed cellularity Hodgkin disease: This is the second most common type
(15% to 30%) and is seen mostly in older adults (although it can occur at any
age). It can start in any lymph node but most often occurs in the upper half of
the body.
Lymphocyte-rich Hodgkin disease: This subtype accounts for about 5% of
Hodgkin disease cases. It usually occurs in the upper half of the body and is
rarely found in more than a few lymph nodes.
Lymphocyte-depleted Hodgkin disease: This is the least common form of
Hodgkin disease, making up less than 1% of cases. It is seen mainly in older
people. The disease is more likely to be advanced when first found, in lymph
nodes in the abdomen as well as in the spleen, liver, and bone marrow.

Nodular lymphocyte predominant Hodgkin disease (NLPHD) accounts for

about 5% of Hodgkin disease. The cancer cells in NLPHD are large cells called
popcorn cells (because they look like popcorn), which are variants of Reed-
Sternberg cells. NLPHD usually starts in lymph nodes in the neck and under the arm.
It can occur in people of any age, and is more common in men than in women
(Hodgson et.al, 2016).
Cotswold staging system: staging system is a way for the cancer care team to
sum up the extent of a cancers spread. The staging system for Hodgkin disease is
known as the Cotswold system, which is a modification of the older Ann Arbor
system. It has 4 stages, labeled I, II, III, and IV.
If Hodgkin disease affects an organ outside of the lymph system, the letter E
is added to the stage (for example, stage IE or IIE). If it involves the spleen, the letter
S is added.

Stage I: Either of the following means that the disease is stage I:

Hodgkin disease is found in only 1 lymph node area or lymphoid organ such
as the thymus (I).
The cancer is found only in 1 area of a single organ outside the lymph system
(IE).

Stage II: Either of the following means that the disease is stage II:
Hodgkin disease is found in 2 or more lymph node areas on the same side of
(above or below) the diaphragm the muscle beneath the lungs that
separates the chest and abdomen (II).

3
 The cancer extends locally from one lymph node area into a nearby organ
(IIE).

Stage III: Either of the following means that the disease is stage III:
Hodgkin disease is found in lymph node areas on both sides of (above and
below) the diaphragm (III).
Hodgkin disease is in lymph nodes above and below the diaphragm, and has
also spread to a nearby organ (IIIE), to the spleen (IIIS), or to both (IIIES).
Stage IV: Any of the following means that the disease is stage IV:

Hodgkin disease has spread widely through 1 or more organs outside of the
lymph system. Cancer cells may or may not be found in nearby lymph nodes.
Hodgkin disease is found in organs in 2 distant parts of the body (and not in
nearby lymph nodes).
Hodgkin disease is in the liver, bone marrow, lungs (other than by growing
there directly from another site), or cerebrospinal fluid (the liquid that
surrounds the brain and spinal cord).

4
 II. ANATOMY AND PHYSIOLOGY

The immune system comprises cells and molecules with specialized roles in
defending against infection and invasion by other organisms. Its major components
include the bone marrow, the white blood cells (WBCs) produced by the bone
marrow, and the lymphoid tissues. Lymphoid tissues include the thymus gland, the
spleen, the lymph nodes, the tonsils and adenoids, and similar tissues in the
gastrointestinal, respiratory, and reproductive systems.
The lymph system (also known as the lymphatic system) is part of the
immune system, which helps fight infections and some other diseases. It also helps
fluids move in the body. The lymph system is composed mainly of:

Lymphoid tissue: includes the lymph nodes and related organs (see
below) that are part of the immune and blood-forming systems
Lymph: a clear fluid that travels through the lymph system, carrying
waste products and excess fluid from tissues, as well as lymphocytes
and other immune system cells
Lymphatic vessels: small tubes, similar to blood vessels, through which
lymph travels to different parts of the lymph system
Lymphoid tissue is made up mainly of cells called lymphocytes, a type of
white blood cell. The 2 major types of lymphocytes are B lymphocytes (B cells) and T
lymphocytes (T cells). Normal B cells and T cells have different jobs.
The bone marrow is the production site of the WBCs involved in immunity.
Like other blood cells, lymphocytes are generated from stem cells, which are
undifferentiated cells. Descendants of stem cells become lymphocytes, the B
lymphocytes (B cells), and the T lymphocytes (T cells). B lymphocytes mature in the
bone marrow and then enter the circulation. T lymphocytes move from the bone

5
marrow to the thymus, where they mature into several kinds of cells capable of
different functions.

B lymphocytes: B cells help protect the body from germs (bacteria and
viruses) by making proteins called antibodies. The antibodies attach to the
germs, marking them for destruction by other parts of the immune system.
Almost all cases of Hodgkin disease start in B lymphocytes.
T lymphocytes: There are several types of T cells, and each has a special job.
Some T cells directly destroy certain kinds of bacteria or cells infected with
viruses or fungi. Other types of T cells play a role in either boosting or slowing
the activity of other immune system cells.
The major sites of lymphoid tissue are:
Lymph nodes: Lymph nodes are bean-sized
collections of lymphocytes and other immune
system cells throughout the body, including
inside the chest, abdomen, and pelvis. They can
sometimes be felt a small lumps under the skin in
the neck, under the arms, and in the groin.
Lymph nodes are connected t each other by a
system of lymphatic vessels.
Lymph nodes get bigger when they fight an
infection. Lymph nodes that grow because of
infection are called reactive or hyperplastic
nodes. These oen hurt when they are touched.
People with sore throats or colds might have
enlarged neck lymph nodes. An enlarged lymph
node is not always a sign of a serious problem,
but it can be a sign of Hodgkin disease.
The spleen: composed of red and white pulp,
acts somewhat like a filter. The red pulp is the site where old and injured red blood
cells are destroyed. The white pulp contains concentrations of lymphocytes. The
lymph nodes are distributed throughout the body. They are connected by lymph
channels and capillaries, which remove foreign material from the lymph before it
enters the bloodstream. The lymph nodes also serve as centers for immune cell
proliferation.
Bone marrow: The bone marrow is the spongy tissue inside certain bones, which is
where new white blood cells (including some lymphocytes), red blood cells, and
platelets are made.
Thymus: The thymus is a small organ behind the upper part of the breastbone and
in front of the heart. It is important in the development of T lymphocytes.
Adenoids and tonsils: These are collections of lymphoid tissue in the back of the
throat. They help make antibodies against germs that are breathed in or swallowed.
Digestive tract: The stomach, intestines, and many other organs also have
lymphoid tissue.

6
 III. PATHOPHYSIOLOGY

Non-modifiable Factors: Precipitating Factors:

Family history Socioeconomic status

Ethnicity/Race: American, Epstein-Barr virus infection
Canadian, Asian Environment
Gender: Male Cell injury
Age: mostly children 15 below

Genetic material damage

Hyperplasia
Legend:

Pathway Recurrent injury resulting to Metaplasia

Signs/Symptoms
Prolonged injury causing mutation
Diagnostics of oncogenes

Disruption of tumor suppressor genes

Cell transformation

Transformed cell release Transformed cell release

7
cytokines growth factors
 Reed-Sternberg
Accumulation of Proliferation of malignant and cell formation
Weight loss non-malignant lymph cells
inflammatory cells
Lymph node biopsy
Night sweats

Fever Macrophages secrete TNF Painless enlargement of one or

Chest X-ray
more lymph nodes

Acts on hypothalamus Endogenous pyrogen

Impaired lymph flow from serous cavity CT scan, MRI
or erosion of tumor into pleural cavity
PET scan
Catabolic effect of Mediastinal mass Hepatic involvement or bile
tumor on body duct obstruction
metabolism Skeletal involvement Bone pain
Compress the
trachea Jaundice Suppression of
Selective trapping of
hematopoiesis
nutrients
Dyspnea
Decreased RBC,
Tumor cell CBC count Anemia
WBC, PLT
secrete cachetin

Acts on hypothalamus Suppress synthesis of Fat loss Impaired T lymphocyte function

lipoprotein lipase

Weakness Susceptibility to opportunistic infection

Cachexia

Weight loss

8
Pathophysiology of Hodgkins disease: A narrative

The malignancy initially involves a single lymph node, frequently in the neck
area. Later the cancer spreads to adjacent nodes in an orderly fashion and then to
organs via the lymphatics. The T lymphocytes appear to be defective, and the
lymphocyte count is decreased. The atypical cell used as a marker for diagnosis of
Hodgkins lymphoma is the Reed-Sternberg cell, a giant cell present in the lymph
node. Hodgkins disease can be subdivided into four subtypes, based on the cells
found at biopsy. There are various staging systems available. Staging for Hodgkins
lymphoma uses the diaphragm as the differential landmark. The Ann Arbor staging
system generally defines a stage I cancer as affecting a single lymph node or region
and stage II as affecting two or more lymph node regions on the same side of the
diaphragm or in a relatively localized area. Stage III cancer involves nodes on both
sides of the diaphragm and the spleen. Stage IV represents diffuse extralymphatic
involvement such as bone, lung, or liver. Extensive testing is required to stage
lymphomas accurately.
Multiple myeloma is a neoplastic disease of unknown etiology occurring in older
adults and involving the plasma cells (mature B lymphocytes involved in production
of antibodies). An increased number of malignant plasma cells replace the bone
marrow and erode the bone. Blood cell production is impaired, as well as production
of antibodies. Multiple tumors with bone destruction develop in the vertebrae, ribs,
pelvis, and skull. Pathologic or spontaneous fractures at weakened sites in the bone
are common. Hypercalcemia develops as bone is broken down. The tumor cells can
spread throughout the body, into lymph nodes and infiltrating many organs.
Extensive testing is required for the diagnosis.
Radiation, chemotherapy, and surgery are used with much greater success now
than formerly. Although many newer drugs and combinations have been tried, one of
the most effective remains the ABVD combination. For a patient in stage II, three
courses of chemotherapy at 4-week intervals would be suggested, and then the
patients status evaluated. In the advanced stages, remissions are common,
although secondary cancers have occurred in some patients following extensive
treatment.

9
IV. DIAGNOSTIC TESTS
1. Lymph node needle biopsy
- Helps determine the type of
lymphoma. Lymph node biopsies
may be performed by needle
aspiration or by surgical excision.
Preparation:
-Explain to the child and
parents:
The purpose of the test
The method that will be
used to obtain the sample (needle biopsy or surgical excision)
That foods, fluids, and medications are not restricted before the
procedure.
The type of anesthesia to be administered (local infiltration for
needle biopsies, general anesthesia for excisional biopsies if
deeper nodes are to be removed)
That, if an excisional biopsy is performed, sutures or other
material may be used to close the biopsy site
That a dressing will be applied to the biopsy site
That analgesics may be administered after the procedure to
alleviate any discomfort
Nursing considerations:
- Assess dressing or Band-Aid for excessive bleeding.
- Instruct client in care and assessment of the site.
-Inform client of follow-up appointment to remove sutures, if any are
present.
Imaging tests use x-rays, sound waves, magnetic fields, or radioactive
particles to make pictures of the inside of the body. Imaging tests may be
done for a number of reasons, including:

To look for possible causes of certain symptoms, such as enlarged lymph

nodes in the chest
To help determine the stage of Hodgkin disease
To help show if treatment is working
To look for possible signs of cancer coming back after treatment

2. Chest X-ray
- Hodgkin disease often enlarges lymph nodes in the
chest, which can usually be seen on a plain chest x-
ray (Kppers et. al, 2006).
Preparation:
-Explain to the child and parents:
The purpose of the test
That the procedure takes about 15
minutes
That foods, fluids, and medications are
not restricted before the procedure
That no sedation or anesthetic is

10
 administered before the procedure
That views may be taken with the client in various positions on
the x-ray table or in an x-ray chair
That the area to be examined will be immobilized or the client will
be asked to remain still during the procedure
Cover the genital area with a lead apron.
Nursing considerations:
-Remove any articles from the infants body and protect vital areas
-Ensure safety and comfort after the test.

3. CT scan, MRI
- The CT scan uses x-rays to make detailed cross-sectional images of the
body. Unlike a regular x-ray, CT scans can show the detail in soft tissues
(such as internal organs). This scan can help tell if any lymph nodes or organs
in your body are enlarged (Forero-Torres et.al, 2009P). CT scans are useful
for looking for Hodgkin disease in the neck, chest, abdomen, and pelvis. MRI
test is rarely used in Hodgkin disease, but if the doctor is concerned about
spread to the spinal cord or brain, MRI is very useful for looking at these
areas.
Preparation:
- Explain to the parents:
That the procedure requires from 45 minutes to 2 hours,
depending on the extent of the imaging and whether a contrast
medium is used. Assess for any allergies when contrast is to be
used.
That foods and fluids are withheld for 4 hours before the
procedure if a contrast medium is used.
That a sedative may be used.
Nursing considerations
-Advise parents to resume food intake and increase fluid intake to
eliminate contrast medium, if one was used
- Note and report nausea, skin rash, sweating, palpitations, respiratory
changes, and changes in vital signs.

4. Positron Emission Tomography (PET) Scan

- For a PET scan, a form of
radioactive sugar (known as
fluorodeoxyglucose or FDG) is
injected into the blood. The
amount of radioactivity used is
very low and will pass out of the
body within a day or so.
Because cancer cells in the
body are growing quickly, they
absorb large amounts of the
sugar. You then lie a table in the
PET scanner for about 30
minutes while a special camera creates a picture of areas of radioactivity in
the body. They can help spot small areas in the body that might be

11
 lymphoma, even if the area looks normal on a CT scan (Swerdlow SH,
Campo E, Harris NL, et al., 2008).
Preparation:
- Explain to the parents:
That the procedure takes 30 to 60 minutes, depending on the organ
to be examined.
That foods and fluids are withheld for 4 hours before the procedure
since a contrast medium shall be used.
That a sedative may be used.
Nursing considerations
-Advise parents to resume food intake and increase fluid intake to
eliminate contrast medium
- Note and report nausea, skin rash, sweating, palpitations, respiratory
changes, and changes in vital signs.
-Assist to change positions slowly to avoid hypotension

5. CBC count
- a test that measures the levels of different cells in the blood. Hodgkin
disease cells dont show up in the blood, but a CBC can sometimes reveal
signs of Hodgkin disease. For example, anemia (not having enough red blood
cells) can be a sign of more advanced Hodgkin disease. A high white blood
cell count is another possible sign, although it can also be caused by
infection.
-The erythrocyte sedimentation rate (ESR)a general marker of
inflammationmay be elevated in Hodgkin lymphoma. An elevated ESR has
been associated with worse prognosis. However, the ESR is a nonspecific
test that should not be used for Hodgkin lymphoma screening.
Preparation:
-Explain to the child and parents:
The purpose of the test
The procedure, including the site from which the blood sample is
likely to be obtained
That momentary discomfort may be experienced when the skin is
pierced
Nursing considerations:
- For children, a doll may be used as the patient for demonstration
purposes.
- Apply the necessary pressure to the puncture site until the bleeding
stops. If oozing continues, elevate the extremity and apply a pressure
type of dressing.
- Remain with the client until the bleeding has completely stopped.
- If the client is experiencing excessive and lingering pain or syncope,
allow the client to lie down and rest.
- Assess for extreme anxiety and signs of possible shock state such as
tachycardia and hypotension.
- Check the venipuncture site in 5 minutes for hematoma formation.

12
6. Bone marrow aspiration

-if Hodgkin disease has been

diagnosed, these tests are done
sometimes to tell if it has reached
the bone marrow. The bone marrow
aspiration and biopsy are usually
done at the same time. The samples
are taken from the back of the pelvic
(hip) bone, although in some cases
they may be taken from other bones
(Castellino, 2015).

Preparation:
-Explain to the child and parents:
That it will be done at the bedside by a physician and requires
about 20 minutes
The general procedure, including the sensations to be expected
(momentary pain as the skin is injected with local anesthetic and
again as the needle penetrates the periosteum, the pulling
sensation as the specimen is withdrawn)
That discomfort will be minimized with local anesthetics or
systemic analgesics
That the site may remain tender for several weeks
Nursing considerations:
- For children, a doll may be used as the patient for demonstration
purposes.
- Assisting the client to lie on the biopsied side, if the iliac crest was
entered, or supine, if the vertebral bodies were used, to maintain
pressure on the site for 10 to 15 minutes.
- Ensure that a signed consent has been obtained.
- Provide bed rest for at least 30 minutes after the procedure.
- Assess puncture site every 10 to 15 minutes for bleeding. Apply an
ice bag to the puncture site to alleviate discomfort and prevent bleeding

13
V. INTERVENTIONS

A. General Nursing Interventions

1. Provide patient and family with information about the
possible treatments such as chemotherapy and
radiation therapy. Include its benefits and
disadvantages.
2. Allow verbalization of feelings regarding concerns and
anxieties.
3. Teach parents and child about risk of infection and
prevent them by: Washing hands after contact with
possible source of infection, immediately cleanse any
abrasion or wound of mucous membranes or
skin, monitor temperature and report fever or
other sign of infection immediately. Avoiding
crowds and people with illnesses as well as
avoiding raw or undercooked foods will be a
helpful measure.
4. Explain to patient that radiation therapy may
cause sterility
5. Encourage frequent small meals, using
bland and soft diet at mild temperatures
6. Teach child and parents to avoid irritants, such as
exposure to tobacco, spices, and extreme food
temperatures.
7. Encourage mouth care at least twice per day and
after meals using gentle flossing, soft toothbrush and
mild mouth rinse.
8. Avoid rubbing, powders, deodorants, lotions, or
ointments (unless prescribed) or application of heat
and cold to treated area of radiation therapy.
9. Assess temperature and vital signs, breath
sounds, LOC, and skin and mucous
membranes frequently for signs of infection.
10. Offer food that appeal to olfactory, visual, and
tactile senses to enhance patients appetite.
11. Suggest ways to address fatigue such as:
energy conservation and avoid overexertion,
encourage to rest frequently and balance
activity and rest periods.
12. Administer antiemetic before chemotherapy
13. Explain the effects to be expected and cope
with those effects accordingly with the parents

14
B. Medical Interventions
1. Pharmacological Interventions
a) Chemotherapeutic agents for HL: Initial treatment commonly with ABV
regimen of doxorubicin (Adriamycin), bleomycin (Blenoxane), vinblastine
(Velban)

b) Chemotherapeutic agents for NHL: various regimens available, including CHO

regimen of cyclophosphamide (Cytoxan), doxorubicin (Adriamycin), vincristine
(Oncovin)

*DRUG STUDY FOR EACH MENTIONED DRUG IS LOCATED BELOW.

15
Generic Name:
Classification: Contraindication: Side/Adverse Effects: Nursing Intervention:
Doxorubicin HCl
Hypersensitive to Respiratory: Monitor vital signs
Brand Name:
drug components recall pneumonitis frequently during
Adriamycin
Anitobiotic Use cautiously in CV: administration and
Antineoplastic children Cardiomyopathy, ECG pattern.
Pharmacologic class: Do not use with changes in ECG Report significant
Anthracyclines cyclophosphamide to GI: diarrhea, changes.
prevent cardio toxicity esophagitis, Monitor for bone
Dosage, timing & route Mechanism of Action nausea, marrow
stomatitis, depression.
Inhibits DNA and RNA vomiting. Assess for
60 to 75 mg/m2 I.V. as synthesis by forming a GU: red urine bleeding (bleeding
single dose every 21 complex with DNA;
Derm: alopecia, gums, bruising,
days; or 25 to 30 mg/m2 action is cell-cycle S- petechiae. Avoid
photosensitivity
I.V. daily for 2 to 3 days phase specific. Also has
Reproductive: IM injections and
every 3 to 4 weeks; immunosuppressive taking rectal
sterility
properties, causing temperatures
Death of rapidly Hematology:
anemia, Apply pressure to
replicating cells, venipuncture sites
particularly malignant leukopenia
Phlebitis at site for 10min.
ones. Encourage fluid
intake of 2000
3000 ml/day.
Administer
antiemetic before
therapy
Assess IV site
regularly.
Discuss possibility
of hair loss

16
Generic Name:
Classification: Contraindication: Side/Adverse Effects: Nursing Intervention:
Bleomycin Sulfate
Hypersensitivity to CNS: Aggressive Monitor vital signs
Brand Name:
drug components behavior, before and
Blenoxane
Antibiotic May cause infant disorientation, frequently during
Antineoplastic harm weakness therapy.
Pharmacologic class: RESP: Pulmonary Assess for fever
Anti-tumor antibiotics fibrosis and chills. May
CV: Hypotension occur 36 hr after
Dosage, timing & route Mechanism of Action GI: Anorexia, administration and
vomiting, stomatitis last 412 hr.
0.25 to 0.5 unit/kg I.V., Inhibits DNA and RNA
SKIN: Monitor for
I.M., or SubQ, or 10 to synthesis. Causing death anaphylactic
Hyperpigmentation,
20 units/m2 1 to 2 times/ of rapidly replicating reactions (fever,
alopecia, rashes
week cells, particularly
HEMATOLOGY: chills, hypotension,
malignant ones. wheezing)
Anemia, leukopenia
Phlebitis Discontinue and do
METABOLISM: not resume
Weight loss bleomycin if
pulmonary toxicity
occurs
Modify diet as
tolerated and
weigh weekly
If ulceration occur
in oral mucosa,
encouraged to use
sponge brush and
rinse mouth with
water

17
Generic Name:
Classification: Contraindication: Side/Adverse Effects: Nursing Intervention:
Vinblastine
Hypersensitivity to CNS: Seizures, Monitor vital signs
Brand Name:
drug components weakness regularly
Velban
Decreased bone RESP: Monitor for bone
Analgesic marrow reserve Bronchospasm marrow depression.
Pharmacologic class: GI: nausea, Assess for bleeding
Vinca Alkaloids vomiting, anorexia, (bleeding gums,
diarrhea bruising, petechiae
Dosage, timing & route Mechanism of Action Assess injection site
SKIN: Alopecia,
dermatitis frequently for
Initial2.5mg/m2, single Binds to proteins of
HEMATOLOGY: redness, irritation, or
dose; increase weekly mitotic spindle, causing inflammation
Anemia, leukopenia,
as tolerated by 1.25mg/ me taphase arrest. Cell
thrombocytopenia Instruct patient to
m2 to maximum of replication is stopped as
Phlebitis inspect oral mucosa
7.5mg/m2. a result (cell cycle for redness and
Maintenance one specific for Metaphase). ulceration. Use
increment less than last Death of rapidly sponge brush
dose q 7 days replicating cells,
Instruct patient to
particularly malignant
report symptoms of
ones. Has immuno-
neurotoxicity
suppressive properties
(paresthesia, pain,
difficulty walking,
persistent
constipation)
Caution patient to
avoid crowds and
persons with known
infections.

18
Generic Name:
Classification: Contraindication: Side/Adverse Effects: Nursing Intervention:
Cyclophosphamide
Hypersensitivity to RESP: Pulmonary Monitor vital
Brand Name:
drug components fibrosis signs regularly
Cytoxan Antineoplastic Active infections CV: Myocardial and report any
Immunosuppressant Bone marrow fibrosis, hypotension significant
Pharmacologic class: depression GI: nausea, changes
Alkylating agents vomiting, anorexia Monitor urinary
GU: Cystitis output frequently.
Dosage, timing & route Mechanism of Action
SKIN: Alopecia, To avoid cystitis,
dermatitis encouraged to
Initial2.5mg/m2, single Interferes with DNA
HEMATOLOGY: increase fluid
dose; increase weekly replication and RNA intake; 1000-2000
Anemia, leukopenia,
as tolerated by 1.25mg/ transcription, ultimately ml for children
thrombocytopenia
m2 to maximum of disrupting protein
7.5mg/m2. synthesis (cell-cycle Phlebitis Monitor for bone
marrow
Maintenance one phasenonspecific), depression.
increment less than last causing death of rapidly Assess for
dose q 7 days replicating cells, bleeding
particularly malignant Weigh weekly.
ones. Also has immune Antiemetics may
suppressant action in be given 30mins
smaller doses. before the therapy
Anorexia and
weight loss can
be minimized by
feeding frequent
light meals
Instruct patient to
take dose in early
morning.

19
Generic Name:
Classification: Contraindication: Side/Adverse Effects: Nursing Intervention:
Vincristine
Hypersensitivity to CNS: mental status Monitor vital signs
Brand Name:
drug components changes, weakness regularly
Oncovin
Decreased bone RESP: Monitor neurologic
Analgesic marrow reserve Bronchospasm status. Assess for
Pharmacologic class: GI: nausea, paresthesias
Vinca Alkaloids vomiting, anorexia, (numbness, tingling,
diarrhea pain), loss of deep
Dosage, timing & route Mechanism of Action SKIN: Alopecia, tendon reflexes
dermatitis Assess injection site
IV (Children >10 kg): Binds to proteins of
HEMATOLOGY: frequently for
1.52mg/m2 single mitotic spindle, causing redness, irritation, or
Anemia, leukopenia,
dose; may repeat metaphase arrest. Cell inflammation
thrombocytopenia
weekly. replication is stopped as
Phlebitis Monitor intake and
a result (cell cycle output. Weigh daily.
IV (Children <10 kg): specific for Metaphase).
Discuss alopecia
50mcg/kg single dose; Death of rapidly
Instruct patient to
may repeat weekly. replicating cells,
report symptoms of
particularly malignant
neurotoxicity
ones. Has immuno-
(paresthesia, pain,
suppressive properties
difficulty walking,
persistent
constipation)
Caution patient to
avoid crowds and
persons with known
infections.

20
2. Surgical and Special Procedures

a) Bone marrow transplantation. Blood and marrow stem cell transplantation are
potentially lifesaving treatments with application in many malignant and
nonmalignant disorders. Several decades of research have advanced this
technology from an experimental treatment of last resort to the preferred method
of intervention for selected diseases. Although the basic procedures are now well
established, this field continues to grow rapidly through ongoing research in
areas such as nonmyeloablative allogeneic transplants, the application of biologic
response modifiers to modulate the immune response, and the use of donor
lymphocyte infusions to prevent or treat post-transplant relapse (American
Cancer Society, 2016).
Autologous Bone Marrow Transplantation: Bone marrow is removed from the
patient during an operative harvesting procedure, frozen, and reinfused after the
patient has undergone high-dose chemotherapy and possibly radiotherapy.
Advantages: readily available, usually lower morbidity and mortality than
allogeneic bone marrow transplantation (BMT). Disadvantages: operative
procedure, marrow must be disease free, sufficient quantity of cellular marrow
must be aspirable, in most cases has higher rate of relapse than allogeneic bone
marrow transplantation (Linch DC, Winfield D, Goldstone AH, et al., 2003).

Nursing Interventions:
PRE-OPERATIVE
Assess the child's developmental level.
Assess the parents' and child's understanding of the surgical
procedure.
Assess psychological preparation of the child for hospitalization and
surgery (Does the child understand what will happen? Do the
parents know the importance of telling the child the truth, and do
they have a good understanding of the procedure? Does the child
have preconceived ideas from peers that may pose a threat?)
Obtain the child's baseline vital signs along with his height and
weight.
Assess the child's hydration status.
Prepare the child specifically for what to expect postoperatively
Perform the necessary criteria for the transplant as per hospital
guidelines and protocol
Talk to the child about the new things to be seen in the operating
room, and clear up any misconceptions. Whenever possible, allow
the child to see, touch, and examine equipment, such as
thermometers, beds, tubing, and suction equipment.
Help the parents prepare the child by talking at first in general terms
about surgery and progressing to more specific information.

POST-OPERATIVE

Encourage the parents to stay with the child and help provide care.

21
 Observe for potential complications (bleeding, hypotension caused
by fluid loss).
Instruct patient to slowly resume normal activities gradually during
the week after donation.
Instruct patient to keep aspiration sites clean and dry and observe
for signs of infection (redness, swelling, warmth or discharge at
sites, fever, malaise).
Provide adequate analgesia and instruct patient about pain
management.
Arrange follow-up appointment with primary care provider in 2 to 3
weeks for a CBC.
Encourage the parents to be with the child when the child awakens.
When the parents must leave, reassure the child that they will return

22
 VI. NURSING CARE PLANS
Ineffective breathing pattern related to pressing of trachea due to swelling of nodes as evidenced by trouble breathing, cough and
chest pain secondary to Hodgkins disease

ASSESSMENT OBJECTIVES INTERVENTION RATIONALE

May exhibit: Short term: Independent: 1. To detect early stages of

At the end of 30 minutes to 1 1. Monitor and record respiratory failure.
Accessory muscle use hour, the client will be able to: respiratory rate and depth 2. To detect decreased or
Abnormal heart rate Maintain respiratory rate at least every 4 hrs. adventitious breath
response to activity within baseline 2. Auscultate breath sounds sounds.
Altered respiratory rate or Show and express at least every 4 hrs. 3. Which will promote
depth or both feelings of comfort when 3. Assist patient to Fowlers expansion of lungs and
Dyspnea breathing. position. provide comfort
Nasal flaring Achieve maximal lung 4. Support upper extremities 4. Assist with lung
Pursed lip breathing expansion with adequate with pillows, providing a expansion allowing
ventilation table and cover it with a proper ventilation.
pillow to lean on. 5. Turning and
Long term: 5. Turn and reposition repositioning prevent
At the end of 6 hours to patient at least every 2 hr. skin breakdown and
24 hours, the client will Establish a turning improve lung expansion
be able to: Regain schedule for the and prevent atelectasis
arterial blood gases to dependent patient. Post 6. To conserve energy and
baseline. schedule at bedside and avoid overexertion.
Maintain heart rate, monitor frequency. 7. Such activities and play
rhythm, and blood 6. Assist patient with ADLs simplify moving and
pressure within expected as needed turning for many patients
range during periods of 7. Encourage active and allow them to
activity. exercise: Provide a strengthen some upper
Demonstrate skill in therapeutic play body muscles while
conserving energy while appropriate for age. achieving developmental
carrying out ADLs with 8. Teach patient about milestones.

23
ASSESSMENT OBJECTIVES INTERVENTION RATIONALE
assistance from the pursed lip breathing, 8. To promote participation
parents abdominal breathing, and in maintaining health
relaxation techniques status and improve
(deep breathing, ventilation
meditation, guided 9. This enables caregivers
imagery) to participate in patients
9. Teach parents to assist care and encourages
patient with ADLs in a them to support patients
way that maximizes independence
patients potential. 10. To improve patients self-
10. Provide emotional concept and motivate
support and patient to perform ADLs.
encouragement to child 11. To maintain an
and parents acceptable level of
oxygen at the tissue level
Collaborative:

11. Administer oxygen, as

ordered

24
Hyperthermia related to increased metabolic rate and infection as evidenced by fever, flushed warm skin secondary to Hodgkins
Disease
ASSESSMENT OBJECTIVES INTERVENTION RATIONALE
Independent: Independent:
May exhibit: Short term:
At the end of 15 minutes, the 1. Monitor heart rate and 1. To evaluate
Fever client will remain: rhythm, blood pressure, effectiveness of
Flushed, warm skin Afebrile respiratory rate, LOC and interventions and monitor
Increased heart rate and Alert and responsive level of responsiveness, for complications.
RR Exhibit moist mucous and capillary refill time 2. Because insensible fluid
Weakness membranes every 14 hours loss increases by 10%
Decreased appetite 2. Determine patients for every 1.8F (1C)
Seizures Long term: preferences for oral increase in temperature,
At the end of 2 hours, the client fluids, and encourage patient must increase
will be able to: patient to drink as much fluid intake to prevent
Maintain good skin turgor as possible, unless dehydration.
Achieve adequate food contraindicated. 3. To obtain an accurate
intake and rest comfortably 3. Take temperature every core temperature.
14 hr 4. Nonpharmacologic
4. Use nonpharmacologic measures lower body
measures to reduce temperature and
excessive fever, such as promote comfort.
removing sheets, Sponging reduces body
blankets, and most temperature by
clothing; placing ice bags increasing evaporation
on axillae and groin; and from skin. Tepid water is
sponging with tepid used because cold water
water. Explain these increases shivering,
measures to child and thereby increasing
parents. metabolic rate and
5. Monitor vital signs every causing temperature to
15 min for 1 hr and then rise.

25
ASSESSMENT OBJECTIVES INTERVENTION RATIONALE
as indicated 5. Prolonged hyperthermia
may lead to
Collaborative: complications such as
6. Administer antipyretics as seizures.
prescribed and record Collaborative:
effectiveness. 6. Antipyretics act on
hypothalamus to regulate
temperature.

26
Imbalanced nutrition: less than body requirements related to related to hypermetabolic state, distress and fatigue as evidenced by
weakness, weight loss, pale conjunctiva and mucous membranes, changes in appetite and eating habits, nausea, vomiting and
secondary to Hodgkins disease

ASSESSMENT OBJECTIVES INTERVENTION RATIONALE

May exhibit: Short term: Independent: Independent:

At the end of 30 minutes to 6
Body weight greater than hours, the client will be able to: 1. Obtain and record patients 1. To ensure keeping an
20% under ideal weight Consume the needed weight every day at the accurate record of
Diarrhea calories per meal to achieve same time weight.
daily requirement. 2. Monitor fluid intake and 2. To provide adequate fluid
Loss of body weight
Demonstrate good appetite output every 8 hr. replacement.
despite adequate food 3. Provide a diet prescribed 3. To ensure that the
intake Long term: for the patients specific patients dietary
Weakness of muscle At the end of 1 week, the client condition and preferences restrictions are followed
required for chewing or will be able to: 4. Keep snacks at the as much as possible
swallowing Maintain good skin turgor bedside 4. To allow the patient to eat
Achieve adequate food 5. Approach patient and small amounts frequently.
intake and rest comfortably parents in a 5. This demonstrates
Gain intended pounds per nonjudgmental manner unconditional positive
week and show progressive 6. Teach self-healing respect for the patient.
development of proper techniques to both the 6. These techniques can be
nutrition. patient and family such as used to reduce anxiety
meditation, guided and increase self-
imagery, yoga, and prayer. reliance.
Teach patient how to 7. Helps in meeting the daily
incorporate the use of self- caloric intake
healing techniques in requirements for the
carrying out usual daily child.
activities. 8. To enhance patients
7. Encourage nutritious, appetite.

27
ASSESSMENT OBJECTIVES INTERVENTION RATIONALE
high-calorie, and fortified 9. Patients autonomy must
fluids to increase nutrient be respected. Control
density. For infants, use over patients actions is
24 to 30 cal/oz rather legitimate only when
than 20 cal/oz. For older danger is posed to
children, suggest fruit patient or others.
smoothies using whole
milk and ice cream. Collaborative:
8. After obtaining patients 10. For dietary management
food preferences, attempt 11. To assist patient in
to obtain desired foods complying with
for the patient. Offer food modification of behavior
that appeal to olfactory, 12. Adds in the nutritional
visual, and tactile senses needs of the child.
9. Acknowledge patients
right to choose not to
comply with prescribed
regimen.

Collaborative:
10. Refer patient to a
dietitian or nutritional
support team
11. Refer family to
community resources and
support groups available
12. Administer multivitamin
supplements as
prescribed

28
Impaired tissue integrity related to high-dose radiation therapy secondary to treatment of Hodgkins disease

ASSESSMENT OBJECTIVES INTERVENTION RATIONALE

Possibly evidenced by: Short term:

Dry skin and mucous At the end of 30 minutes, the Independent: Independent:
membranes client will be able to:
Poor skin turgor Maintain stable vital signs 1. Explain the therapy to 1. To encourage
Swollen lymph nodes Have normal skin color and patient and family compliance.
Low blood pressure turgor members 2. Encourages compliance
Itchiness Experience relief from 2. Instruct patient and family and allowing skin site
Redness on site immediate signs and members in a skin care improvement
Vomiting symptoms (pain, ulcers, regimen 3. To detect imbalances and
color changes, and edema). 3. Monitor intake and output for baseline data.
Maintain and adequate fluid and record daily weight. 4. Adequate hydration
and urine volume 4. Maintain adequate delays onset of adverse
hydration. effects of the radiation
Long term: 5. Avoid rubbing, powders, therapy
At the end of 12 hours, the client deodorants, lotions, or 5. To minimize and or
will be able to: ointments (unless reduce itching and
Have normal skin turgor and prescribed) or application redness
moist mucous membranes of heat and cold to 6. To avoid harboring
Maintain collateral treated area. secondary infection.
circulation. 6. Encourage patient to 7. To avoid reducing arterial
Exhibit comfort and regain keep treated area clean blood supply
energy. and dry, bathing area 8. To avoid dryness and
gently with tepid water photosensitivity reactions
and mild soap. 9. Allow rinsing of mucous
7. Encourage wearing membranes thus
loose-fitting clothes. preventing dryness
8. Advise patient to protect 10. To prevent from getting
skin from exposure to nauseous and excessive

29
ASSESSMENT OBJECTIVES INTERVENTION RATIONALE
sun, chlorine, and vomiting
temperature extremes.
9. Encourage mouth care at
least twice per day and
after meals using gentle
flossing, soft toothbrush
and mild mouth rinse.

Collaborative:

10. Administer or teach self-

administration of pain
medication or antiemetic
before eating or drinking,
if needed.

30
Risk for infection related to altered immune function and tissue destruction as possibly evidenced by fever, hypermetabolic state,
redness and dryness of skin secondary to Hodgkins disease chemotherapeutic agents and radiation therapy

ASSESSMENT OBJECTIVES INTERVENTION RATIONALE

Possibly evidenced by: Short term: Independent: Independent:

At the end of 1 hour, the client
Vulnerability to infection will be able to: 1. Monitor and record
Fever Remain safe and temperature after surgery 1. As this may signal onset
Redness and dryness of comfortable at least every 4 hr; report of infection
skin site Maintain good personal elevations immediately 2. Elevated total WBC count
Dry oral mucous and oral hygiene 2. Monitor WBC count, as indicates infection.
membranes Maintain normal ordered. Report Markedly decreased
Weight loss temperature and vital elevations or WBC count may indicate
Weakness signs depressions. decreased production
Poor appetite Maintain good appetite 3. Perform hand hygiene resulting from extreme
before and after providing debilitation or severe lack
Long term: care, and direct patient to of vitamins and amino
At the end of 1 week, the client do this before and after acids.
will be able to: meals and after using 3. To avoid spread of
Practice safety bathroom, bedpan, or pathogens
precautions in and out urinal 4. To prevent colonization of
the house 4. Offer frequent oral bacteria and reduce risk
Parents are able to attain hygiene of descending infection.
nutritional needs 5. Provide skin care, Disease and malnutrition
Identify infection risk particularly over bony may reduce moisture in
factors, and signs and prominences mucous membranes of
symptoms of infection 6. Assist patient when mouth and lips.
necessary to ensure that 5. Help prevent venous
perianal area is clean stasis and skin
after elimination. breakdown.
7. Instruct patient and family 6. Cleaning perineal area by

31
ASSESSMENT OBJECTIVES INTERVENTION RATIONALE
members about good wiping from the area of
hand hygiene, factors least contamination
that increase infection (urinary meatus) to the
risk, and signs and area of most
symptoms of infection contamination (anus)
8. Unless contraindicated, helps prevent
encourage fluid intake of genitourinary infections.
3,0004,000 ml daily 7. To encourage patient to
9. Instruct patient to participate in care and
immediately report loose modify lifestyle to
stools or diarrhea maintain optimum health.
8. To help stabilize weight,
Collaborative: improve muscle tone and
mass, and aid wound
10. Use sterile water for healing.
humidification or 9. Which may indicate need
nebulization of oxygen. to discontinue or change
11. Arrange for protective antibiotic therapy;
isolation if patient has 10. This prevents drying and
compromised immune irritation of respiratory
system. Monitor flow and mucosa, impaired
number of visitors. 11. These measures protect
patient from pathogens in
environment.

32
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A. Books

Pillitteri, A. (2010). Maternal and Child Health Nursing. Philadelphia: Lippincott

Williams & Wilkins.

Sparks, S., Taylor, C. (2011). Nursing Diagnosis Pocket Guide. Wolters

Kluwer, Lippincott Williams and Wilkins; Philadelphia

Boyer, M. (2010). Brunner and Suddarth's Textbook of Medical-Surgical

Nursing. Philadelphia: Lippincott Williams & Wilkins.

Deglin, J., Vallerand, A. (2010). Davis Drug Guide for Nurses. F.A. Davis
Company; Philadelphia

B. Electronic Sources

Castellino AM. New ILROG guidelines for pediatric Hodgkins lymphoma.

Medscape Medical News. Oncology. WebMD Inc. Available at
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2017.

American Cancer Society (2016). https://www.cancer.org/cancer/

hodgkinlymphoma/ detectiondiagnosisstaging/signsandsymptoms.html.
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Arya LS, Dinand V. Current strategies in the treatment of childhood Hodgkins

disease. Indian Pediatr. 2005 Nov. 42(11):1115-28.

Forero-Torres A, Leonard JP, Younes A, Rosenblatt JD, Brice P, Bartlett NL.

A Phase II study of SGN-30 (anti-CD30 mAb) in Hodgkin lymphoma or
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Hodgson DC, Dieckmann K, Terezakis S, Constine L. Implementation of

contemporary radiation therapy planning concepts for pediatric
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Kppers R, Yahalom J, Josting A. Advances in biology, diagnostics, and

treatment of Hodgkin's disease. Biol Blood Marrow Transplant. 2006
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Linch DC, Winfield D, Goldstone AH, et al. Dose intensification with

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Hodgkin's disease: results of a BNLI randomised trial. Lancet. 1993 Apr
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Robertson VL, Anderson CS, Keller FG, Halkar R, Goodman M, Marcus RB,
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34