NCP Lymphomas


Malignant lymphomas are cancers of the lymphoid system and include distinct entities defined by clinical, histologic, immunologic, molecular, and genetic characteristics. Based on histologic characteristics, lymphomas are divided into two major subgroups: Hodgkin’s disease and non-Hodgkin’s lymphoma.


The etiology of Hodgkin’s disease is unclear, but indirect evidence indicates a viral cause. Signs and symptoms of Hodgkin’s disease are distinctive—patients present with a slow, insidious, superficial lymphadenopathy with lymph (cervical, supraclavicular, mediastinal) nodes that are firm, rubbery, and freely movable. The disease spreads in a generally predictable manner to contiguous lymph nodes via lymphatic channels.

Because of many histologic subtypes and ongoing biological, pathological, and clinical studies, classifying lymphomas is controversial. In 1999, the World Health Organization suggested a change in the subtyping of Hodgkin’s disease that would assist physicians in selecting treatment protocols.

Treatment for Hodgkin’s disease may include radiation, a combination of radiation and chemotherapy, or chemotherapy alone. The cure rate for newly diagnosed cases is higher than 90%, making Hodgkin’s disease one of the most treatable forms of cancer. Bone marrow transplant or peripheral progenitor (stem) cell transplants with high-dose chemotherapy are recommended for patients who have relapsed/failed primary chemotherapy regimen.


Non-Hodgkin’s lymphoma is a malignancy of the B lymphocyte and T lymphocyte cell systems. Abnormal lymphocytes accumulate and form masses in lymph tissue such as the lymph nodes, spleen, or other organs. Malignant lymphocytes travel through the circulation to distant sites. Common extranodal sites include the lungs, liver, gastrointestinal tract, meninges, skin, and bones. Most patients with non-Hodgkin’s lymphoma fall into two broad categories related to their clinical features: the nodular indolent type, and the diffuse, aggressive lymphomas. Malignant lymphocytes accumulate in lymph nodes. If the normal follicular structure of the nodes remains intact, the lymphoma is called follicular or nodular. When malignant cells destroy the follicles, the lymphoma is considered diffuse. For treatment purposes, they may be separated into two categories: low-grade lymphoma and aggressive lymphoma (which includes intermediate-grade and high-grade lymphomas). Treatment for non-Hodgkin’s lymphomas may includes watching and waiting, radiation, chemotherapy (usually multiple combinations of antineoplastic agents), monoclonal antibodies (rituximab [Rituxan]), peripheral progenitor (stem) cell transplant or bone marrow transplant. With or without treatment, low-grade lymphomas can transform into a more aggressive lymphoma, or the tumor replaces the hematopoietic and lymphoid tissue, which leads to multiple systemic dysfunction and death. Intermediate- and high-grade lymphomas tend to be more responsive to treatment.


Acute inpatient care on a medical unit for initial evaluation and treatment, then at community level. This plan of care addresses potential complications that may be encountered in acute care or hospice settings. (The nurse is referred to other related cancer care plans for nursing interventions related to treatments such as radiation, chemotherapy, and bone marrow transplant.)


Anemias (iron deficiency, pernicious, aplastic, hemolytic)
Psychosocial aspects of care
Spinal cord injury (acute rehabilitative phase) (complication related to spinal cord involvement/compression)
Transplantation (postoperative and lifelong)
Upper gastrointestinal/esophageal bleeding

Patient Assessment Database


May report:
Fatigue, weakness, or general malaise
Loss of productivity and decreased exercise tolerance
Excessive sleepiness

May exhibit:
Diminished strength, slumping of the shoulders, slow walk, and other cues indicative of fatigue
Night sweats


May report:
Palpitations, angina/chest pain

May exhibit:
Tachycardia, dysrhythmias
Cyanosis and edema of the face and neck or right arm (superior vena cava syndrome—obstruction of venous drainage from enlarged lymph nodes is a rare occurrence)
Scleral icterus and a generalized jaundice related to liver damage and consequent obstruction of bile ducts by enlarged lymph nodes (may be a late sign)
Pallor (anemia), diaphoresis, night sweats


May report:
Increased stress, e.g., school, job, family
Fear related to diagnosis and possibility of dying
Concerns about diagnostic testing and treatment modalities (chemotherapy and radiation therapy)
Financial concerns: Hospital costs, treatment expenses, fear of losing job-related benefits because of lost time from work
Relationship status: Fear and anxiety related to being a burden on the family

May exhibit:
Varied behaviors, e.g., angry, withdrawn, passive


May report:
Changes in characteristics of urine and/or stool, vague abdominal pain
History of intestinal obstruction, e.g., intussusception or malabsorption syndrome (infiltration from retroperitoneal lymph nodes)

May exhibit:
Abdomen: RUQ tenderness and enlargement on palpation (hepatomegaly); LUQ tenderness and enlargement on palpation (splenomegaly)
Decreased output, dark/concentrated urine, anuria (ureteral obstruction/renal failure)
Bowel and bladder dysfunction (spinal cord compression occurs late)


May report:
Anorexia/loss of appetite
Dysphagia (pressure on the esophagus)
Recent unexplained weight loss equivalent to 10% or more of body weight in previous 6 mo with no attempt at dieting

May exhibit:
Edema of the lower extremities (inferior vena cava obstruction from intra-abdominal lymph node enlargement associated with non-Hodgkin’s lymphoma)
Ascites (inferior vena cava obstruction related to intra-abdominal lymph node enlargement)


May report:
Nerve pain (neuralgias) reflecting compression of nerve roots by enlarged lymph nodes in the brachial, lumbar, and sacral plexuses
Muscle weakness, paresthesia

May exhibit:
Mental status: Lethargy, withdrawal, general lack of interest in surroundings
Paraplegia (tumor involvement/spinal cord compression from collapse of vertebral body, disc involvement with compression/degeneration, or compromised blood supply to the spinal cord)


May report:
Tenderness/pain over involved lymph nodes, e.g., in or around the mediastinum; chest pain, back pain (vertebral compression); stiff neck; generalized bone pain (lymphomatous bone involvement)
Immediate pain in involved areas following ingestion of alcohol (Hodgkin’s disease)

May exhibit:
Self-focusing; guarding behaviors


May report:
Dyspnea on exertion or at rest; chest pain

May exhibit:
Dyspnea; tachypnea
Dry, nonproductive cough (hilar lymphadenopathy)
Signs of respiratory distress, e.g., increased respiratory rate and depth, use of accessory muscles, stridor, cyanosis
Hoarseness/laryngeal paralysis (pressure from enlarged nodes on the laryngeal nerve)


May report:
History of frequent/recurrent infections (abnormalities in cellular immunity predispose patient to systemic herpes virus infections, TB, toxoplasmosis, or bacterial infections), mononucleosis (higher risk of Hodgkin’s disease in patient with high titers of Epstein-Barr virus), HIV (risk of non-Hodgkin’s lymphoma is 60–100 times higher in these patientscompared with the generalpopulation)
Administration of immunosuppressive drugs after organ transplantation
History/presence of ulcers/perforation, gastric bleeding
Waxing and waning pattern of lymph node size
Cyclical pattern of evening temperature elevations lasting a few days to weeks (Pel-Ebstein fever) followed by alternate afebrile periods; drenching night sweats without chills

May exhibit:
Unexplained, persistent fever higher than 100.4°F (38°C) without symptoms of infection
Asymmetrical, painless, yet swollen/enlarged lymph nodes (cervical nodes most commonly involved, left side more than right; then axillary and mediastinal nodes)
Nodes may feel rubbery and hard, discrete and movable
Tonsilar enlargement
Generalized pruritus/urticaria (Hodgkin’s disease)
Patchy areas of loss of melanin pigmentation (vitiligo)


May report:
Concern about fertility/pregnancy (although disease does not affect either, treatment does)
Decreased libido


May report:
Familial risk factors (higher incidence among families of Hodgkin’s patients than in general population)
Occupational exposure to pesticides and herbicides or other chemicals, e.g. benzene, creosote, lead, formaldehyde, paint thinner

Discharge plan considerations
DRG projected mean length of inpatient stay: 7.4 days; with surgical intervention: 9.2 days
May need assistance with medical therapies/supplies, self-care activities and/or homemaker/
maintenance tasks, transportation, shopping
Refer to section at end of plan for postdischarge considerations.


These diseases are staged according to the microscopic appearance of involved lymph nodes and the extent and severity of the disorder. Accurate staging is most important in deciding subsequent treatment regimens and prognosis.
Blood studies may vary from completely normal to marked abnormalities. In stage I, few patients have abnormal blood findings.
WBC: Variable, may be normal, decreased, or markedly elevated.
Differential WBC: Neutrophilia, monocytosis, basophilia, and eosinophilia may be found. Complete lymphopenia (late symptom).
RBC and Hb/Hct: Decreased.
Erythrocytes: Stained RBC examination: May demonstrate mild to moderate normocytic, normochromic anemia (hypersplenism).
Platelets: Decreased or may be elevated.
ESR: Elevated during active stages and indicates inflammatory or malignant disease. Useful to monitor patients in remission and to detect early evidence of recurrence of disease.
Erythrocyte osmotic fragility: Increased.
Coombs’ test: Positive reaction (hemolytic anemia) may occur; however, a negative result usually occurs in advanced disease.
C-reactive protein (CRP) serum titer: May be positive in patients with Hodgkin’s disease.
Serum cryoglobulins: May be positive in patients with Hodgkin’s disease.
Serum haptoglobin: May be elevated in patients with Hodgkin’s disease and in those with cancer of the lung, large intestine, stomach, breast, and liver.
Serum iron and TIBC: Decreased.
Serum alkaline phosphatase: Elevation may indicate either liver or bone involvement.
Serum LDH: Elevated.
Serum copper: Elevation may be seen in exacerbations.
Serum calcium: May be elevated when bone is involved.
Serum uric acid: Elevation related to increased destruction of nucleoproteins and liver and kidney involvement.
BUN: May be elevated when kidney involvement is present.
Serum creatinine, bilirubin, antistreptolysin (ASL); creatinine clearance: May be done to detect organ involvement.
Gamma globulin: Hypergammaglobulinemia is common; may occur in advanced disease.
Chest x-ray: May reveal mediastinal or hilar adenopathy, nodular infiltrates, or pleural effusions.
X-rays of thoracic, lumbar vertebrae, proximal extremities, pelvis, or areas of bone tenderness: Determine areas of involvement and assist in staging.
IVP: May be done to detect renal involvement or ureteral deviation by involved nodes.
Whole lung tomography or chest computed tomography (CT) scan: Done if hilar adenopathy is present to reveal possible involvement of mediastinal lymph nodes.
Abdominal and pelvic CT scan: May be done to rule out diseased nodes in the abdomen and pelvis and associated organs.
Abdominal ultrasound: Evaluates extent of involvement of retroperitoneal lymph nodes.
Bone scans: Done to detect bone involvement.
Gallium scan: Proven useful for detecting recurrent nodal disease, especially above the diaphragm.
Lymphangiogram: Historically a very important diagnostic tool. Seldom done today because of newer technologies.
Bone marrow biopsy: Determines bone marrow involvement, which is seen in advanced stages.
Lymph node biopsy: Establishes the diagnosis of Hodgkin’s disease based on the presence of the Reed-Sternberg cell.
Mediastinoscopy: May be performed to establish diagnosis (presence of lymphoma in mediastinal lymph nodes).
Staging laparoscopy or laparotomy: May be done to obtain specimens of retroperitoneal nodes, of both lobes of the liver, and/or to remove the spleen. (Splenectomy is controversial because it may increase the risk of infection and is currently not usually done unless patient has clinical manifestations of stage IV disease.)


1. Provide physical and psychological support during extensive diagnostic testing and treatment regimen.
2. Prevent complications.
3. Alleviate pain.
4. Provide information about disease process/prognosis and treatment needs.


1. Complications prevented/minimized.
2. Dealing with individual situation realistically.
3. Pain relieved/controlled.
4. Disease process/prognosis, possible complications, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.

Refer to CPs: Cancer, Leukemias, for general nursing diagnoses and interventions to accomplish corresponding nursing priorities/discharge goals.