case study
H.J. is a 46-year-old man diagnosed with non-Hodgkin lymphoma (NHL) 4 months ago. He finished receiving his third of six chemotherapy courses 5 days ago. Yesterday morning, he was seen at his oncologist’s office for malaise, muscle weakness, and palpitations. He had splenomegaly on examination. A computed tomography (CT) scan of the abdomen showed metastatic disease in the liver and spleen. He is admitted to the hospital with progressive disease.
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Basic Metabolic Panel (BMP)
| Na | 136 meq/L (136 mmol/L) |
| K | 6.1 meq/L (6.1 mmol/L) |
| Cl | 97 meq/L (97 mmol/L) |
| CO2 | 28 meq/L (28 mmol/L) |
| Glucose | 98 mg/dL (5.4 mmol/L) |
| Blood urea nitrogen (BUN) | 54 mg/dL (19.28 mmol/L) |
| Creatinine | 2.7 mg/dL (239 mcmol/L) |
| Ca | 6.3 units/L |
| Total protein | 5.4 g/dL (54 g/L) |
| Albumin | 2.8 g/dL (4.0 mcmol/L) |
| Phosphorus | 4.8 mg/dL (1.55 mmol/L) |
| Uric acid | 20.7 mg/dL (1.23 mmol/L) |
| Total bilirubin | 0.8 mg/dL (13.7 mcmol/L) |
| Alkaline phosphatase | 172 units/L (2.87 µkat/L) |
| Aspartate transaminase (AST) | 254 units/L (4.23 µkat/L) |
| Alanine transaminase (ALT) | 74 units/L (1.23 µkat/L) |
| Lactate dehydrogenase (LDH) | 214 IU/L (3.57 mckat/L) |
- Interpret H.J.’s admitting BMP panel.
H.J.’s BMP shows an increase potassium, uric acid, and phosphorus, low calcium, and elevated BUN, and creatinine. These lab findings indicate renal damage related to Tumor Lysis Syndrome.
- Based on these values, which common oncologic emergency is H.J. experiencing?
Tumor Lysis syndrome
- Describe the pathophysiology of this condition.
The chemo and radiation H.J. is receiving is causing massive cell destruction. This cell destruction releases large amounts of intracellular components consisting of potassium, phosphate, DNA and RNA that are metabolized by the liver into uric acid. The extra cellular components lead to hyperkalemia, hyperphosphatemia, hypocalcemia and hyperuricemia.
- What assessment findings related to this diagnosis would you expect in H.J.?
Hyperkalemia, hyperphosphatemia, hypocalcemia, hyperuricemia.
Weakness, muscle cramping, nausea, vomiting, diarrhea.
Chvostek’s and Trousseau’s and tetany as a result of hypocalcemia and possible seizures.
Possible acute kidney injury due to hyperuricemia
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Complete Blood Count (CBC)
| White blood cells (WBCs) | 1500/mm3 (1.5 x 109/L) |
| Neutrophils | 66% |
| Lymphocytes | 16% |
| Monocytes | 15% |
| Eosinophils | 5% |
| Hemoglobin (Hgb) | 8.3 g/dL (83 g/L) |
| Hematocrit (Hct) | 23.6% |
| Platelets | 21,000/mm3 (21 x 109/L) |
- Based on his laboratory values, name 3 additional problems for which H.J. is at risk.
Low WBC places the patient at risk for infection
His platelets are critically low which puts him at risk for bleeding
His hemoglobin and hematocrit are low, causing anemia
- What are your nursing priorities right now?
Monitoring intake and output, vital signs, and EKG changes. Monitor neuro status while giving fluids to maintain renal function. Give allopurinol and sodium bicarb per MD order.
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Medication Record
IV 0.9% saline at 150 mL/hr
100 mEq sodium bicarbonate in the first liter of IV fluid
Rasburicase 6 mg IV now
Allopurinol 500 mg twice daily orally
Furosemide 40 mg IV now then every 6 hours
Sodium polystyrene sulfonate 15 g orally every 6 hours
Aluminum hydroxide 2 caps orally with meals
CASE STUDY PROGRESS
The oncologist confirms a diagnosis of acute tumor lysis syndrome (TLS) and writes several orders for H.J.
7. What is the expected outcome associated with each medication H.J. is receiving?
The IV NS will maintain renal function
Sodium bicarb will alkalinize the acidic urine
Rasburicase will decrease uric acid levels
Allopurinol will decrease risk for secondary gout
Furosemide will increase excretion of uric acid and potassium
Sodium polystyrene sulfonate will decrease serum potassium levels
Aluminum hydroxide will reduce phosphate levels
8. After giving sodium polystyrene sulfonate, it is important for you to monitor H.J.’s:
- Urine output
- Bowel sounds
- Peripheral pulses
- Level of consciousness
9. What major complication of TLS is H.J. at risk for and why?
Acute Kidney Injury due to increased uric acid levels
10. Name 3 signs and symptoms of this complication you will assess for in H.J.
Metabolic acidosis
Oliguria
Leukocytosis
11. List 4 independent nursing interventions that you would include in H.J.’s plan of care and the reason for each.
Daily weights to monitor possible fluid overload
Incentive spirometry to prevent pneumonia infection
Sit him up if he experiences any difficulty breathing
Encourage rest to decrease metabolic demand
12. The best way to prevent infection in a patient such as H.J. is
- Giving prophylactic antibiotics
- Placing him in reverse isolation
- Limiting his intake of fresh fruits and vegetables with skins
- Practicing good handwashing by all who are in contact with him
CASE STUDY PROGRESS
Twenty-four hours after admission, H.J.’s laboratory tests are repeated.
Chart View
Basic Metabolic Panel
| Na | 138 meq/L (138 mmol/L) |
| K | 4.8 meq/L (4.8 mmol/L) |
| Cl | 109 meq/L (109 mmol/L) |
| CO2 | 26 meq/L (26 mmol/L) |
| Glucose | 148 mg/dL (8.2 mmol/L) |
| BUN | 34 mg/dL (12.14 mmol/L) |
| Creatinine | 2.4 mg/dL (212 mcmol/L) |
| Ca | 7.3 units/L (1.83 mmol/L) |
| Total protein | 5.4 g/dL (54 g/L) |
| Albumin | 2.8 g/dL (4.06 mcmol/L) |
| Phosphorus | 3.8 mg/dL (1.23 mmol/L) |
| Uric acid | 0.5 mg/dL (29.7 mcmol/L) |
| Total bilirubin | 1.0 mg/dL (17.1 mcmol/L) |
| Alkaline phosphatase | 96 units/L (1.6 µkat/L) |
| AST | 49 units/L (0.8 µkat/L) |
| ALT | 48 units/L (0.8 µkat/L) |
| LDH | 224 IU/L (3.73µkat/L) |
13. Interpret H.J.’s laboratory results. Is his condition improving?
Yes, potassium, calcium and phosphorus are all within normal limits. BUN and creatinine are still elevated, but are trending down towards normal. His uric acid levels have been overcorrected, but may self correct once medications are lessened.
CASE STUDY PROGRESS
Because H.J.’s condition has stabilized, the oncologist orders another round of chemotherapy.
14. Because the TLS is just resolving, what interventions would you include in your plan of care?
Lowering the dose or stop allopurinol because his uric acid levels are very low. Monitor I/O, labs, and EKG. If H.J. continues with his chemo, continue with the Rasburicase, sodium polystyrene sulfonate, and aluminum hydroxide so another episode of TLS doesn’t occur. Continue IV hydration since his BUN and creatinine are still elevated.
15. What precautions should you take when administering H.J.’s chemotherapy to reduce the risk for injury? Select all that apply.
- Independently verify the completeness of the drug order and infusion rate.
- Dispose of any equipment that held the drug in special biohazard containers.
- Scrub skin that comes into contact with the drug for 5 minutes with a surgical brush.
- Wear goggles, powdered gloves, and a disposable, fluid-resistant, long-sleeved gown.
- If using a peripheral site, place a disposable drape under the arm where the drug will be infused.
- Use a Luer-Lok connector to attach the drug tubing to the main IV line, using the IV port closest to H.J.
16. The UAP you are working with states she is unfamiliar with caring for patients receiving chemotherapy. What instructions do you give to the UAP to reduce her risk for injury?
Use appropriate PPE when interacting with the patient to prevent infection and avoid direct contact with any bodily fluids. Dispose of equipment in a biohazard bag.
17. Which tasks can you delegate to the UAP? Select all that apply.
- Giving IV fluids as prescribed
- Assisting H.J. with oral hygiene
- Practicing good hand washing technique
- Determining the need for antiemetic therapy
- Reporting the amount and type of oral fluid intake
- Taking vital signs and recording them every 4 hours
CASE STUDY OUTCOME
H.J. does not experience any acute kidney injury. He is discharged home 3 days later after finishing this round of chemotherapy. He will be following up with the oncologist in 1 week.
