BY MEENAKSHI KAUSHIK, PGIMS, ROHTAK.

1. MULTIPLE MYELOMA:---
• Multiple myeloma ia a malignant disease of
the most mature form of B lymphocytes, the
plasma cell.
• It is not classified as a LYMPHOMA.
• Plasma cell secrete immunoglobulins, protein
necessary for antibody production to fight
infection.

2. Plasma cells:--
• Plasma cell: A type of white blood cell that
produces and secretes antibodies. A plasma
cell is a fully differentiated, mature
lymphocyte in the B cell lineage. As with most
cell types, plasma cells can mutate to give rise
to cancer. Plasma cell malignancies include
plasmacytoma, multiple myeloma,
Waldenstrom macroglobulinemia, and plasma
cell leukemia. Also known as plasmac

5. • Incidence usually occurs after 40 years of age.
• Male : female is 2:1.
• More common in americans.
• Median survival rate is 3 to 5 years.
• Death usually results due to infection.

6. ETIOLOGY:--
• The exact causes is UNKNOWN--
• There are many prediction regarding the
etiology of multiple myeloma , these
include—
1. Chronic inflammation.
2. Chronic hypersensitivity reaction.
3. Viral disease.
4. Radiation exposure.

8. PATHOPHYSIOLOGY:--
• The disease process involves excessive
production of plasma cells.
• Plasma cells are activated plasma B cells,
which produces immunoglobulins that
normallys protect the body .
• However in multiple myeloma malignancy
plasma cells infiltrated the bone marrow and
produce abnormal and excessive amount of
immunoglobulins.

9. Contd..
• Usually IgG, IgA, IgD, IgE immunoglobulins
formed.
• This abnormal immunoglobulin formed as
myeloma protein.
• Furthermore , plasma cells production of
excessive and abnormal amount of of cytokins
also plays an important role in pathological
process of bone destruction.

10. Contd..
• As myeloma protein increase normal plasma
cells are reduced which furthermore
decreases the body’s normal immune
response.
• Ultimately the plasma cell destroyes bone and
invades the lymph nodes, spleen and the
kidneys.

12. CLINICAL MANIFESTATION:--
• The condition develops slowly and insidiously.
• The patient often does not manifest
symptoms until the disease advance at which
time
• Skeletal pain is the major manifestation.
• Pain in the pelvis, spine, & ribs is particularly
common.
• Osteoporosis develops as myeloma destroyes
more bones.

13. Contd..
• Vertebra destruction can lead to collapse of
vertebra which causes compression of spinal
cord, requiring emergencies measures to
prevent paraplegia.
• Loss of bone integrity can cause pathological
fracture.
• Hypercalcium may develop due to loss of
calcium.

14. Contd..
• Hypercalcium will cause:--
– Renal changes such as polyuria, hyperuricemia, and
renal failure can also occur.
– In GI anorexia, excessive thirst,
dehydration,constipation.
– In neuro confusion, altered mental status and coma
can occur.
There may be anaemia, thrombocytopenia,
granulocytopenia all of these are due to replacement
of normal bone marrow elements with plasma cells.

15. ASSESSMENT AND DIAGNOSTIC
FINDINGS:--
• Chief complain of bone or back pain with
elevated level of total protein.
• Elevated monoclonal protein spike in the
serum or urine or light chain in the urineis
major criterion for diagnosis.
• X’RAY shows lytic bone lesion.
• Prescence of anaemia and hypercalcium.
• Bone marrow biopsy.

16. MANAGEMENT:--
• There is NO CURE FOR MULTIPLE MYELOMA..
• Even BMT is considered by most authorities to
extends remission rather than possible cure.
• Treatment modalities includes:--
– Chemotherapy by cyclophosphamide, melphalan,
doxorubicin, vincristine is the primary mode of
treatment.
– Corticosteroids particularly dexamethasone is
used.

17. contd..
• For pain management:--suitable analgesic is
used.
• Pamidronate for skeletal pain, it reduces the
osteoclast activity of bone . Some research
believes that pamidronate have activity
against myeloma cells themselves.
• The biological agent alpha interferone has
been successful in maintaing remission in
selected types of multiple myeloma.

18. CONTD…
• Radition theraphy:--
• Radition theraphy is very useful in
strengthening a specific bone lesion or spinal
cord compression.
• It is also useful in reducing bone pain.

19. NURSING MANAGEMENT:--
• GOALS:--
• Reducing pain.
• Preventing pathological fracture.
• Maintaing hydration.
• Prevention of infection.
• Monitoring for sign of complication.
• Educating the patient and family members.

20. Nursing diagnosis:--
• Pain related to osteoclasts activities or due to
disease progression.
– Assess the level of pain and for the type of analgesic
required.
– Consult with doctor while formulating pain
management plan.
– Administrate the ordered analgesic.
– NSAIDS are very useful for mild to moderate type of
pain.
– NSAIDS can also be used with opioid analgesics for
severe pain.

21. Contd..
• High risk for pathological fracture related to
decrease bone mass or increased bone clast
activity.
– Activity restriction.
– Patient educated regarding this , that he she should
not lift more than 2-3 kg.
– Body mechanics are maintained properly.
– Braces are usually advised to support spinal columan.
– Skillful handling of patients during moving and
turning.
– Proper positioning and safety in toilet for aged
patients.

22. Contd..
• Risk for dehydration related to hypercalcemia
and inability to take required fluids.
– Assess the level of hydration.
– Increase oral intake if possible if not then
administer iv fluids.
– Maintain intake output charts.

23. Contd..
• Risk for infection related to altered immunological function
of body.
• Aseptic technique should be followed in every procedure.
• Patients should be kept in isolated room if possible and if
not then limit the visitors or visitors with any type of
infection.
• Avoid going in crowded or dusty area.
• Mopping should be done in the room instead of brooming.
• Strict hand washing.
• Proper care of any extrenous devices.
• If patient catheterized then care of the catheter.

24. Contd..
• High risk for potential complications
– Watch for sign of any complication..
– It can be renal problem, neurological, GIT,
Heamatology.
– Watch for sign of hypercalcemia , polyuria,
anaemia, confusion or altered mental status.
– Report to physician.
– Keep patient under close observation.
– Do as per doctors. Advise.

25. Contd..
• Knowledge deficit related to disease process
and potential complication.
• Family and patient is taught about potential
complication.
• Advise regarding careful handling of patients.
• Maintaing good body mechanics, preventing
going into high hill places, on unequal
surfaces.