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Hodgkin’s Lymphoma Nursing Guide

This course is intended as a Quick Reference for Hodgkin’s lymphoma and will provide an overview as well as nursing considerations utilizing the nursing process.

Etiology and Epidemiology

Hodgkin's Lymphoma Definition

Hodgkin’s lymphoma is a type of malignancy that affects the lymphatic system, and it is marked by the presence of Reed-Sternberg cells, which are large cancer cells not found in non- Hodgkin’s lymphoma (Robertson, 2018). Although the disease originates in the lymph system, the cancer can spread to almost any organ or tissue, including the bone marrow, liver, and spleen. 

It is estimated that there were about 8,830 new cases of Hodgkin’s lymphoma and 960 deaths for the year 2021. The disease is most common in early adulthood, and then the risk rises again for individuals in late adulthood. The average age of diagnosis is 39 years. Approximately 87% of individuals with Hodgkin’s lymphoma have a 5 year survival rate (American Cancer Society [ACS], 2021b). 

Causes/risk factors include (ACS, 2021a): 

  • Epstein-Barr virus (EBV) 
  • Age 
  • Male 
  • Family history 
  • History of HIV 
  • Suppressed immune system 
  • Auto immune disorders 

 

Hodgkin's Lymphoma ICD-10 Code: C81.90

  • Unspecified, unspecified site

 

Hodgkin's Lymphoma Diagnosis 

Signs and symptoms include (American Society of Clinical Oncology [ASCO], 2020b): 

  • Lymph nodes in the neck, underarm or groin area that are painless, swollen, and do not resolve within a few weeks 
  • Fever of unknown origin that does not resolve 
  • Unexplained weight loss 
  • Night sweats, usually soaking 
  • Pruritus (can be widespread and may be severe) 
  • Fatigue 
  • Lymph node pain caused by ingesting alcohol 
  • Cough 
  • Dyspnea 
  • Chest tenderness 
  • At times, no symptoms are present 

To confirm a diagnosis of Hodgkin’s lymphoma the following should be done (ASCO, 2020a): 

  • An exploration of the history of the present illness 
  • Physical exam 
  • A core needle biopsy 
  • A tissue biopsy (removal of the affected lymph node) 
  • A mediastinoscopy may need to be done if the chest area is affected 

Additional testing to help form an effective treatment plan includes (ASCO, 2020a): 

  • Complete blood count (CBC) 
  • Erythrocyte sedimentation rate (ESR) 
  • Liver function tests 
  • Kidney function tests 
  • Computed tomography (CT or CAT) scan 
  • Positron emission tomography (PET) or PET-CT scan 
  • Magnetic resonance imaging (MRI) 
  • Pulmonary function tests (PFTs) 
  • Echocardiogram (ECHO) 
  • Multigated acquisition (MUGA) scan 
  • Bone marrow aspiration and biopsy (mostly replaced by PET-CT scans) 

If Hodgkin’s lymphoma diagnosis is confirmed, staging may be performed. The stages may be divided into A and B categories. If the cancer is staged as “A,” that means the individual has not had any B symptoms. If the cancer is staged as “B,” the individual has had one or more of the following symptoms: 

  • Unexplained weight loss of more than 10% of baseline body weight during the 6 months prior to diagnosis 
  • Temperature above 100.4°F (38°C) of unknown origin 
  • Soaking night sweats (sometimes excessive sweating during the day) 

 

Hodgkin's Lymphoma Treatment & Management 

Treatment options are determined by the following (ASCO, 2020c): 

  • The type and stage of lymphoma 
  • Possible treatment side effects 
  • PET-CT scan results during treatment 
  • The individual’s preferences 
  • General health status 

First line chemotherapy includes (ASCO, 2020c): 

  • ABVD: Doxorubicin (Adriamycin®), bleomycin (Blenoxane®), vinblastine (Velban®), and dacarbazine (Dtic-Dome®). This regimen is the most commonly used treatment. 
  • AAVD: This treatment is similar to ABVD, but brentuximab vedotin (Adcetris®) changes to bleomycin. Brentuximab vedotin targets only cells that have a special protein on the surface called CD30. This is sometimes used for individuals with advanced disease, especially when they have a higher risk of lung problems. 
  • BEACOPP: Bleomycin (Blenoxane®), etoposide (VP-16®), doxorubicin (Adriamycin®), cyclophosphamide (Cytoxan®), vincristine (Vincasar PFS®), procarbazine (Matulane®), and prednisone (Deltasone®). This treatment is often used in Europe. Many specialists believe it is more effective, but it does have more severe side effects. 
  • Gemcitabinen (Gemzar®) combined with other drugs. Due to the side effects of the other available treatment regimens, older individuals can have difficulty tolerating those treatment options and gemcitabinen can be better tolerated. 

Second line chemotherapy is used when complete remission is not achieved with the first treatment or if the cancer returns after first line treatment is administered. The goal of the second line treatment is to control the disease, but it is often done in preparation for a bone marrow/stem cell transplant. The second line chemotherapy approach includes (ASCO, 2020c): 

  • ICE: Ifosfamide (Ifex®), carboplatin (Paraplatin®), and etoposide (VP-16®). The regimen is usually given every 2 or 3 weeks for 2 to 3 cycles. 
  • ESHAP or DHAP: ESHAP is etoposide (VP-16®), methylprednisolone (Solu-Medrol®), high-dose cytarabine (Cytosar-U®), and cisplatin (Platinol®, Platinol®-AQ). DHAP is dexamethasone (Decadron®), high dose cytarabine, and cisplatin. ESHAP or DHAP regimens are given every 3 weeks for 2 to 3 cycles. 
  • GVD, Gem-Ox, or GDP: GVD is gemcitabine, vinorelbine (Navelbine®), and doxorubicin. Gem-Ox is gemcitabine and oxaliplatin (Eloxatin®). GDP is gemcitabine, dexamethasone, and cisplatin. These treatments are either given 2 weeks in a row followed by an off-week or every other week. 
  • Brentuximab vedotin: This regimen is usually given every 3 weeks for up to 16 cycles, although sometimes it is given every 4 weeks. This treatment is being evaluated alone or in combination with chemotherapy or immunotherapy prior to bone marrow/stem cell transplantation for cases of recurrent disease. The FDA has also approved this chemotherapy regimen for individuals post transplantation who are at a high risk for recurrence. 
  • Bendamustine (Treanda®): Bendamustine is generally given every 4 weeks. It can be combined with other medications to treat cases of recurrence. 

Immunotherapy is also known as biologic therapy. It is FDA approved for Hodgkin’s lymphoma that has recurred or progressed after several treatments, including an autologous transplantation and usually has mild side effects. This therapy incudes (ASCO, 2020c): 

  • Nivolumab (Opdivo®) 
  • Pembrolizumab (Keytruda®) 

Radiation therapy includes the following (ASCO, 2020c): 

  • Involved-site radiotherapy 
  • Intensity modulated radiotherapy (IMRT) 
  • Proton therapy 

Controlled breathing during radiation therapy treatment may help smaller areas to be more successfully treated. Side effects depend on area being treated; usually resolved once treatment is complete. Improvements in treatment have significantly decreased long term side effects, but some late effects can still occur. For example, if radiation is given to the neck, thyroid damage can occur; if given to the chest, blood vessels and valves can be damaged. 

 

Bone marrow transplantation/stem cell transplantation includes (ASCO, 2020c): 

  • Autologous (AUTO) transplant: 
    • The individual’s own stem cells are used. 
    • The stem cells are gathered post-treatment and then frozen. 
    • This allows for stronger chemotherapy doses to be given so that residual cancer cells are destroyed. 
    • Stem cells are the given by intravenous infusion so the bone marrow and blood cells can recover from the intensive, high dose chemotherapy. 
  • Allogeneic (ALLO) transplant: 
    • Donor stem cells, whose tissue matches the individual on a genetic level, are obtained. 
    • Human leukocyte antigen (HLA) typing is done to determine a donor match. 
    • The donor is usually a close relative but can be an unrelated person. 
    • Chemotherapy is given to prevent the individual’s immune system from damaging the donor’s cells. The donor’s immune system is used to extinguish the cancer cells. 

 

Nursing Considerations 

Use the nursing process to develop a plan of care for individuals. The nursing assessment (with common findings listed), diagnoses, interventions, expected outcomes, and education for Hodgkin’s lymphoma are listed below. 

 

Assessment 

  • Assess for signs and symptoms. 
  • Keep in mind that sometimes no symptoms are present. 
  • Check for any side effects from the treatments provided. 
  • Assess for the presence of infection. 
  • Determine if the individual and caregiver require emotional support services. 
  • Assess for any knowledge deficit regarding diagnosis, side effects, and treatment, including bone marrow transplant if applicable. 

 

Nursing Diagnosis/Risk For 

  • Activity intolerance 
  • Anxiety 
  • Comfort alteration 
  • Fatigue 
  • Fear 
  • Infection 
  • Respiratory alteration 

 

Interventions 

  • Administer chemotherapy, medications, and/or blood products as ordered and according to established guidelines. 
  • Coordinate care between specialists. 
  • Explain all procedures such as bone marrow aspiration. 
  • Manage chemotherapy side effects. 
  • Prepare and care for the individual during bone marrow transplant process, if indicated. 
  • Provide strict reverse isolation for the individual who has the bone marrow transplant. 
  • Provide information concerning the disease, treatment, side effects and long-term issues. 
  • Encourage the individual and caregiver to ask questions and make informed decisions concerning treatments. 
  • Provide emotional support for the individual and caregiver. 
  • Report any abnormal side effects of treatment such as infection, low blood counts, or any other acute changes in patient’s condition. 
  • Monitor: 
    • Lab results 
    • Chemotherapy side effects 
    • Infection 
    • Pain control 
    • Emotional status 
    • Treatment response 

 

Expected Outcomes 

The individual will: 

  • Tolerate treatment 
  • Remain free from infection 
  • Be informed about diagnosis, treatment, and potential complications 
  • Be aware of when to contact healthcare provider 
  • Seek out emotional support as needed 

 

Individual/Caregiver Education 

  • Chemotherapy is generally given over the course of many months at routine intervals. 
  • Chemotherapy side effects are multiple and common. 
  • Infections are a constant risk, and antibiotics are important for prevention as well as treatment. 
  • The individual should report any signs of infection or other unusual symptoms immediately. 
  • Crowds and individuals who are contagious should be avoided. 
  • Information on bone marrow transplantation, when appropriate. 
  • Radiation therapy may be given in conjunction with chemotherapy. 
  • Treatment can cause anemia and that will need to be treated with medication and possibly blood transfusions. 
  • It is important to keep follow up appointments. 
  • Tests and procedures will need to be done to monitor the response to therapy and to monitor for possible recurrence. 
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Additional Information

Content Release Date 

4/1/2022

Content Expiration

12/31/2025

 

Course Contributor 

Course content for this course was revised by Elizabeth Vaccaro, BSN RN, MSCN. 

Elizabeth Vaccaro earned her Bachelor of Science in nursing from Kean University. She is certified as a Multiple Sclerosis Nurse Educator. Elizabeth has worked in a variety of healthcare settings from the hospital to the pharmaceutical industry which has allowed her to have a great appreciation for all the challenges that span the healthcare field. She has practiced in the hospice setting for nine years in a variety of roles from Case Manager, Educator, and Director of both inpatient and home care hospice. 

 

Resource 

 

References