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Multiple Myeloma Nursing Guide

Content created/revised by Monica Caicedo Orellana, MS, RN, OCN, CNE

Multiple myeloma overview

This course is intended as a Quick Reference for multiple myeloma (MM) and will cover an overview as well as nursing considerations utilizing the nursing process.

Multiple myeloma Etiology and Epidemiology

Multiple myeloma is a malignancy of the plasma cells that develops in the bone marrow.

  • Cause unknown
  • Bone marrow produces irregular and immature plasma cells
  • Normal blood cell production becomes interrupted leading to thrombocytopenia
  • Immature plasma cells continue to produce antibodies, overloading the system causing impaired immunity
  • Plasma cells present in soft tissues invade skeletal structures causing fractures and skeletal lesions

Individuals can be asymptomatic or completely debilitated upon presentation. Immature plasma cells circulating in the blood leads to:

  • Impaired immune functioning
  • Improper antibody production
  • Tissue and bone destruction

Multiple myeloma Incidence

  • There are approximately 149,956 individuals in the U.S. living with multiple myeloma (National Cancer Institute, n.d.). Based on cases between 2014-2018, the rate of new multiple myeloma cases was 7.1 per 1000, 000 people.
  • MM accounts for 1.8% of all new cancer cases
  • The 5-year relative survival for localized (found only in one part of the body) MM is 77.5%
  • Most common in individuals > 40 years of age. Most frequently diagnosed in people aged 65-74.
  • More prominent in males than females

Mortality and Morbidity

  • Significant morbidity from:
    • Spinal cord compression
    • Hypercalcemia
    • Opportunistic infection
    • Pathological fractures
    • Kidney failure
  • Fifteenth leading cause of cancer deaths in the U.S., with a date rate of 3.2 per 100, 000 people between 2015-2019 (National Cancer Institute, n.d.).
  • Plasma cell leukemia at presentation related with high-risk disease and poor prognosis

Multiple myeloma Risk Factors

  • African American descent > other genetic groups
  • History of monoclonal gammopathy with undetermined significance (MGUS) blood dyscrasia diagnosis
  • Increased age
  • Exposure to radiation

Multiple myeloma Diagnosis

History

  • Fatigue and weakness
  • Back pain, sometimes severe
  • Bone pain
  • Pathological bone fractures
  • Loss of weight

Physical Examination

  • Bone marrow aspirate findings, 10-95% immature plasma cells
  • Soft tissue masses
  • Pain over bony structures
  • Symptoms from abnormal blood cells (weakness, fatigue, pallor, petechiae)
  • Hypercalcemia
  • Anemia

Laboratory Tests

  • CBC with differential
  • Peripheral blood smear
  • Creatinine clearance
  • Serum electrolytes, BUN/creatinine
  • Liver function test
  • Calcium, albumin, serum uric acid, LDH, and beta-2 microglobulin
  • C-reactive proteins
  • Serum and urine protein electrophoresis (SPEP and UPEP)
    • Elevated M protein levels hallmark finding
  • Immunoglobulin levels (IgA, IgE, IgG, IgM)
  • 24-hour urine

Radiological and Imaging Studies

  • X-rays of affected areas (pelvis, sacrum, chest, sternum, skull)
    • 75% of individuals with myeloma have osteoporosis, fractures, and lytic lesions on X-ray (OncoLink, 2020)
  • Whole low-dose body CT scan
  • Fluorodeoxyglucose (FDG) Pet/CT scan

Other Studies

  • Initial work up
    • Bone marrow aspiration and biopsy
      • Immunohistochemistry
      • Flow cytometry
    • Plasma cell fluorescence in situ hybridization (FISH) on bone marrow
  • Screening
    • Echocardiogram
    • Hepatitis B, hepatitis C and human immunodeficiency virus (HIV)
    • Plasma cell proliferation
    • HLA typing
    • Whole body MRI without contrast
    • Serum viscosity

Management

General management includes the following:

  • Administration of medications to maintain patient’s comfort
  • Assessment of body systems that may be affected by diagnosis (renal, skeletal, circulatory)
  • Refer patient to oncologist, radiation oncologist
  • Watchful waiting for newly diagnosed with indolent disease
    • Monitor the condition in the early stages without treatment (asymptomatic).
  • Transplant eligibility for those with symptomatic disease based on comorbidities and performance status

Activity

  • As tolerated based upon levels of pain with activity
  • Encourage activities to maintain strength

Diet

  • Well balanced nutrition with increased caloric intake during treatment of with patients losing weight from disease process
  • Increase fluid intake to avoid renal complications

Medications

The following medications might be used for the treatment of MM (National Cancer Institute, n.d.):

  • Corticosteroids
  • Induction chemotherapy for transplant eligible patients
    • VRd (Lenalidomide [Revlimid®], bortezomib [Velcade®] and dexamethasone [Deltasone®])
    • CyBorD (cyclophosphamide [Cytoxan®] + bortezomib [Velcade®] + dexamethasone [Deltasone®])
  • Induction therapy for transplant ineligible individuals includes a monoclonal antibody, daratumumab (Darzalex®) in addition to the induction therapy for transplant eligible patients
  • Maintenance therapy
    • Lenalidomide (Revlimid®)
    • Proteasome inhibitor, ixazomib (Ninlaro®)
  • Myeloma bone disease
    • Bisphosphonates
      • Pamidronate (Aredia®) and zoledronate (Zometa®)
    • Receptor activator of nuclear factor-kappa B ligand (RANKL) monoclonal antibody inhibitor
      • Denosumab (Xgeva®)
  • Autologous stem cell transplantation (ASCT)
  • Radiation therapy
  • Surgery
    • Surgical interventions to remove lesions in the affected areas
    • Laminectomy for correction of vertebral compression

Multiple Myeloma Nursing Plan

Nursing Considerations

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

Assessment

Physical examination findings vary based on extent of disease (Albagoush & Azevedo, 2021):

  • Pallor
  • Tachycardia
  • Tachypnea
  • Petechiae and ecchymoses
  • Edema
  • Bone tenderness
  • Signs of dehydration
  • Signs and symptoms of infection (i.e., pneumonia and pyelonephritis)
  • Response to chemotherapy treatment
  • Level of pain
  • Peripheral neuropathies
  • Vital signs

Nursing Diagnosis/Risk For

  • Anxiety
  • Fear
  • Impaired physical mobility
  • Ineffective individual coping
  • Pain

Interventions

  • Monitor CBC for elevated WBCs, chemistry panels for electrolyte imbalances and renal function.
  • Administration of prescribed medications
  • Encourage patient to verbalize feelings about illness
  • Offer patient frequent, smaller meals with increased amount of fluid daily
  • Offer information about support groups for patient and family
  • Implement protocols to avoid risk for injury related to falls and thrombotic events
  • Management of myeloma bone disease

Expected Outcomes

  • Ability to maintain present condition without complications for as long as possible
  • Exhibit adequate coping skills and supportive environment

Patient/Caregiver Education General Education

  • Educate about risk of infection and need for vaccination if recommended
  • Educate about importance of avoiding nephrotoxic medications (e.g., NSAIDs)
  • Educate patient about disease process and treatment plan
  • Importance of follow up care monitoring especially for those diagnosed asymptomatically
  • International Myeloma Foundation information

Discharge Instructions/Planning

  • Importance of follow up care and biopsies to indicate progression of disease of remission status
  • Importance of following medication therapy as instructed
  • Support group programs and counseling when indicated

Diagnosis and Treatment of Multiple Myeloma

The goal of this course is to provide nurses with knowledge about the diagnosis of multiple myeloma, as well as treatment options and clinical interventions.

View Course

Additional Information

Content Release Date 

4/1/2022

Content Expiration

12/31/2024

Course Contributor

This course was revised by Monica Caicedo Orellana, MS, RN, OCN, CNE. 

Monica Caicedo Orellana, MS, RN, OCN, CNE is a SME writer for Relias with over 16 years of acute care experience in nursing. She obtained her OCN certification in 2008. She has served in several leadership roles in the acute care setting, within the medical surgical division, and in the role of nurse educator. She has mentored nurses in renal and oncology specialties. She has been involved in various institutional committees and quality improvement projects. In 2017, she obtained a CNE certification by the National League for Nursing. Monica is passionate about professional nursing standards and fostering an environment of continuous lifelong learning as an instrument to improve patient care.

References

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