A patient with newly diagnosed multiple myeloma presents with anemia, hypercalcemia, and renal impairment. Which of the following nursing interventions should be prioritized to address the patient's hypercalcemia and prevent further renal damage?

A) Encourage increased oral fluid intake to promote renal excretion of calcium.

B) Administer erythropoiesis-stimulating agents to correct anemia.

C) Provide a high-calcium diet to strengthen bone density.

D) Restrict fluid intake to prevent fluid overload.

A patient diagnosed with multiple myeloma has laboratory results indicating hypercalcemia and declining renal function. Which nursing intervention should be prioritized to address the patient's current condition?

A) Administer intravenous normal saline to promote renal excretion of calcium.

B) Encourage the patient to increase dietary calcium to compensate for bone loss.

C) Restrict fluid intake to prevent further renal impairment.

D) Administer calcium supplements to prevent further decline in bone density.

A patient with multiple myeloma undergoing bisphosphonate therapy for hypercalcemia presents with increased fatigue, confusion, hypotension, and hypocalcemia. Based on the change in her clinical status, what is the most appropriate nursing intervention?

A) Administer IV fluids to address hypotension and monitor blood pressure closely.

B) Increase the dose of bisphosphonate therapy to manage osteolytic activity.

C) Encourage increased oral fluid intake and provide potassium supplements.

D) Initiate hemodialysis immediately to correct renal impairment.

A patient with multiple myeloma on bisphosphonate therapy presents with increased fatigue, confusion, and hypotension. Lab results indicate hypocalcemia and worsening renal function. What is the most appropriate initial nursing intervention?

A) Administer intravenous fluids to address hypotension and support renal function.

B) Encourage increased oral fluid intake to correct hypocalcemia.

C) Discontinue calcium supplementation to prevent further hypocalcemia.

D) Notify the physician to restart bisphosphonate therapy.

A patient with multiple myeloma presents with persistent confusion and generalized weakness despite calcium supplementation. New diagnostic results show increased plasma cells in the bone marrow and positive blood cultures for Staphylococcus epidermidis. Considering the patient's condition, what is the priority nursing intervention?

A) Administer broad-spectrum antibiotics as prescribed to address the potential line infection.

B) Increase calcium supplementation to improve serum calcium levels.

C) Encourage high fluid intake to promote renal function.

D) Initiate isolation precautions to prevent the spread of infection.

A patient with multiple myeloma has shown progression of disease with increased plasma cells in the bone marrow and presents with persistent confusion and generalized weakness. Her calcium levels have slightly improved with supplementation, but renal function remains compromised. Blood cultures are positive for Staphylococcus epidermidis. Which nursing intervention is most appropriate to prioritize at this time?

A) Administer prescribed broad-spectrum antibiotics to treat the potential infection.

B) Increase the dosage of calcium supplementation to further improve calcium levels.

C) Educate the patient on the importance of hydration to support renal function.

D) Coordinate with dietary services to provide a high-protein diet to address muscle weakness.

A patient with multiple myeloma and suspected sepsis is experiencing acute kidney injury with a creatinine level of 3.5 mg/dL and decreased urine output. Which nursing intervention should be prioritized to support renal function and stabilize the patient's condition?

A) Administering intravenous fluids to maintain adequate hydration and renal perfusion.

B) Restricting fluid intake to prevent fluid overload and potential pulmonary edema.

C) Initiating high-dose diuretics to promote urine output and reduce creatinine levels.

D) Encouraging oral fluid intake to improve hydration status and renal function.

A patient with multiple myeloma and suspected sepsis is experiencing a decline in renal function with a creatinine level of 3.5 mg/dL. The healthcare team has initiated intravenous fluids and is considering adjusting the antibiotic regimen. Which nursing intervention is most critical to prioritize at this time?

B) Assess the patient's urine output hourly to evaluate renal perfusion.

A) Monitor the patient's temperature every 4 hours to assess for fever reduction.

B) Assess the patient's urine output hourly to evaluate renal perfusion.

C) Encourage oral intake to prevent dehydration and support renal function.

D) Educate the patient on signs and symptoms of worsening infection.

A patient with sepsis and multiple myeloma is showing signs of renal impairment with elevated creatinine levels and reduced urine output. Which nursing intervention is most critical to prioritize to support the patient's renal function and overall stability?

C) Continue fluid resuscitation to maintain adequate intravascular volume.

A) Administer the prescribed proteasome inhibitor to address multiple myeloma.

B) Monitor urine output and report any further decrease to the healthcare provider immediately.

C) Continue fluid resuscitation to maintain adequate intravascular volume.

D) Educate the patient and family about the potential need for dialysis and its implications.

A patient with sepsis and multiple myeloma is experiencing acute kidney injury and has been recommended for dialysis. The interdisciplinary team is considering introducing a proteasome inhibitor to manage her myeloma. As the nurse, which intervention should you prioritize to support the patient's current treatment plan?

B) Monitor the patient's fluid balance and report any changes in urine output immediately.

A) Administer antipyretics to manage the patient's fever.

B) Monitor the patient's fluid balance and report any changes in urine output immediately.

C) Educate the patient and family about the potential side effects of proteasome inhibitors.

D) Prepare the patient for dialysis and assess for signs of electrolyte imbalances.

multiple myeloma - Nursing Case Study

Pathophysiology

• Primary mechanism: In multiple myeloma, malignant plasma cells proliferate in the bone marrow, disrupting normal blood cell production and causing anemia, increased infection risk, and bleeding disorders.

• Secondary mechanism: These malignant plasma cells produce excessive monoclonal immunoglobulins (M-proteins), which impair normal antibody function, contributing to immunodeficiency and renal damage due to protein deposition in kidneys.

• Key complication: Osteolytic lesions occur due to increased osteoclast activity stimulated by myeloma cells, leading to bone pain, fractures, and hypercalcemia, significantly affecting patient mobility and quality of life.

Patient Profile

Demographics:

62-year-old female, retired school teacher

History:

• Key past medical history: Hypertension, osteopenia, and a history of recurrent respiratory infections

• Current medications: Amlodipine, Calcium supplements, and Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Fatigue and bone pain

• Key symptoms: Persistent back pain, anemia, and recurrent infections

• Vital signs: Blood pressure 145/90 mmHg, heart rate 102 bpm, respiratory rate 22 breaths/min, temperature 37.8°C

Section 1

New Diagnostic Results:

Following the patient's initial presentation, a series of diagnostic tests were performed to further evaluate her condition. A complete blood count (CBC) revealed a significant drop in hemoglobin to 8.5 g/dL, confirming the presence of anemia. Serum protein electrophoresis showed a high level of monoclonal protein (M-protein) at 3.7 g/dL, indicative of multiple myeloma activity. Additionally, serum calcium was elevated at 11.5 mg/dL, correlating with the patient's complaints of bone pain and fatigue and suggesting hypercalcemia due to osteolytic activity. A skeletal survey disclosed multiple osteolytic lesions, particularly in the vertebrae and pelvis, which accounted for the persistent back pain.

These findings prompted further investigation into the renal function, as the excessive M-protein can lead to renal impairment. A basic metabolic panel revealed elevated blood urea nitrogen (BUN) and creatinine levels at 30 mg/dL and 2.2 mg/dL, respectively, indicating a decline in renal function possibly exacerbated by hypercalcemia. Urinalysis showed proteinuria, supporting the hypothesis of kidney damage secondary to monoclonal protein deposition. Given these results, the medical team discussed the initiation of bisphosphonate therapy to address bone resorption and potential renal protective strategies, while considering the need for chemotherapy to manage the plasma cell proliferation.

These diagnostic results emphasize the complexity of multiple myeloma management and create an opportunity for clinical reasoning regarding prioritization of interventions, such as managing hypercalcemia and renal impairment while planning for long-term oncological treatment. As the patient's journey continues, monitoring for further complications, such as renal failure or pathological fractures, remains critical to her care plan.

Section 2

Change in Patient Status:

Shortly after the initiation of bisphosphonate therapy to address the patient's hypercalcemia and osteolytic activity, the medical team noticed a change in her clinical status. The patient began experiencing increased fatigue, confusion, and generalized weakness, prompting a reassessment of her condition. Vital signs revealed hypotension with a blood pressure of 88/56 mmHg, a heart rate of 102 bpm, and a low-grade fever of 99.8°F. These findings, coupled with her recent treatment, raised concerns about potential side effects or complications from the therapy.

Laboratory tests were ordered to investigate the underlying cause of her symptoms. Serum electrolytes showed a significant drop in calcium levels to 7.8 mg/dL, indicating possible overcorrection of hypercalcemia. Additionally, her BUN and creatinine levels had increased further to 38 mg/dL and 2.8 mg/dL, respectively, suggesting worsening renal impairment. A repeat urinalysis confirmed persistent proteinuria, while a blood culture was ordered to rule out infection as a cause of her fever and hypotension.

These developments required immediate clinical reasoning to adjust the patient's management plan. The healthcare team decided to temporarily hold the bisphosphonate therapy and initiate calcium supplementation to address the hypocalcemia. Careful monitoring of renal function and consideration of renal dose adjustments in future treatment plans were prioritized. Additionally, the team prepared for potential interventions to prevent further renal deterioration and evaluated the need for dialysis if renal function continued to decline. This change in patient status highlighted the delicate balance needed in managing multiple myeloma complications and underscored the importance of ongoing assessment and timely intervention.

Section 3

New Diagnostic Results:

Following the decision to hold bisphosphonate therapy and initiate calcium supplementation, the patient was closely monitored. Despite these interventions, her confusion and generalized weakness persisted, prompting additional diagnostic tests to explore other potential causes. A comprehensive metabolic panel was repeated, revealing a slight improvement in calcium levels to 8.2 mg/dL; however, her renal function showed no significant change, with BUN at 40 mg/dL and creatinine slightly up at 3.0 mg/dL. This lack of renal recovery suggested ongoing renal compromise related to her multiple myeloma.

A bone marrow biopsy was conducted to assess the current state of her disease. Results indicated a significant increase in plasma cells, now accounting for 60% of the marrow cellularity, up from 40% in previous evaluations. This finding suggested a progression of the myeloma, potentially explaining her persistent symptoms and complicating her treatment plan. Concurrently, the blood culture results returned positive for Staphylococcus epidermidis, a common skin contaminant but also a potential pathogen in immunocompromised individuals, raising concerns about a possible line infection.

These diagnostic results necessitated a reevaluation of the patient's management strategy. The healthcare team considered the initiation of broad-spectrum antibiotics to address the potential infection while coordinating with a nephrologist to explore renal support options. The progression of her multiple myeloma required a multidisciplinary approach to adjust her therapeutic regimen, potentially considering alternative agents that could offer disease control with a more favorable renal profile. The interplay of infection, renal impairment, and disease progression underscored the complexity of her condition and the need for dynamic, responsive care.

Section 4

New Complications:

Despite the initiation of broad-spectrum antibiotics to combat the potential Staphylococcus epidermidis infection, the patient's condition began to deteriorate further. Within 48 hours, she developed a fever of 102.5°F, accompanied by chills and an increased heart rate of 110 beats per minute. Her blood pressure was noted at 90/60 mmHg, indicating a possible systemic response to infection, suggestive of sepsis. This was a concerning development given her immunocompromised state due to both her multiple myeloma and the intensified plasma cell infiltration in her bone marrow.

In parallel, her renal function continued to decline, with her creatinine rising to 3.5 mg/dL and her urine output decreasing significantly, suggesting acute kidney injury. This renal deterioration was compounded by her multiple myeloma, which was now more aggressive, as evidenced by the increased plasma cells. The healthcare team faced the challenge of managing her sepsis while addressing her worsening renal status. They initiated intravenous fluids to support her blood pressure and renal perfusion, while also considering the adjustment of her antibiotic regimen based on culture sensitivities.

The patient's worsening condition necessitated a reassessment of her treatment priorities, balancing the need to control the infection against the backdrop of her progressing myeloma and declining renal function. The interdisciplinary team, including oncology, nephrology, and infectious disease specialists, convened to refine her care plan. They discussed the potential need for dialysis should her renal function not improve, as well as the possibility of introducing a novel therapeutic agent targeting her multiple myeloma, which might offer better disease control with less renal toxicity. This holistic, adaptive approach was essential in navigating the complex interplay of her multiple conditions.

Section 5

The interdisciplinary team decided to prioritize the management of the patient's sepsis to stabilize her condition, allowing for potential future interventions for her multiple myeloma. In response to the initial interventions, including fluid resuscitation and a refined antibiotic regimen, there was a slight improvement in her vital signs over the next 24 hours. The patient's fever reduced to 101.2°F, and her heart rate decreased to 100 beats per minute, suggesting a partial response to treatment. However, her blood pressure remained low at 92/62 mmHg, indicating ongoing hemodynamic instability.

New diagnostic results provided further insight into her condition. Blood cultures confirmed the presence of Staphylococcus epidermidis, reinforcing the decision to continue the targeted antibiotic therapy. Despite this, her renal function remained a significant concern, with creatinine levels further elevating to 4.2 mg/dL and urine output continuing to dwindle. An emergent renal ultrasound was performed, which revealed no signs of obstruction, suggesting that her renal impairment was likely due to acute tubular necrosis secondary to sepsis and myeloma-associated light chain deposition.

Given the persistent decline in renal function, the nephrology team recommended initiating dialysis to manage her acute kidney injury and prevent further systemic complications. Meanwhile, the oncology team was evaluating the introduction of a proteasome inhibitor, which could potentially stabilize her myeloma with a more favorable renal profile. This proposed treatment shift was discussed with the patient and her family, highlighting the importance of balancing infection control with aggressive myeloma management to improve her overall prognosis. As the team moved forward, careful monitoring and coordinated care were crucial to adapting her treatment plan in response to her evolving clinical status.