NCP Hematopoietic Stem Cell Collection

Hematopoietic Stem Cell Collection

Bone Marrow Transplantation; Bone Marrow Donor; Apheresis; Peripheral Blood Stem Cell Donor; Autologous; Allogenic; Syngeneic

Hematopoietic stem cells (HSCs) normally reside in the bone marrow and can be collected from this compartment via multiple needle aspirations from the iliac crest. When collected from the bone marrow, all blood components are collected (e.g., red blood cells, platelets, plasma), not just the stem cell component. HSCs can be moved or mobilized out of the bone marrow into the bloodstream or peripheral circulation. The mobilization of HSCs into the bloodstream occurs following the administration of certain types of chemotherapy and/or colony-stimulating factors (CSFs) such as G-CSF (Neupogen) or GM-CSF (Leukine). HSCs can then be collected via a procedure known as apheresis. During apheresis, needles are inserted into the arm veins (or a central venous catheter), and blood is passed through an apheresis machine, which separates the blood components. Only the HSCs are removed and the rest of the blood components and volume are returned to the patient. This procedure occurs in the outpatient setting (usually in a blood bank or apheresis center), takes from 2 to 4 hours, and may be repeated for several days until the desired number of HSCs is collected. Most transplants performed today rely almost exclusively on peripheral blood stem cells (PBSCs) rather than bone marrow due to the fact that PBSCs are easier to collect and are associated with more rapid hematopoietic recovery, which results in shortened hospitalizations and decreased costs.

Nursing Diagnosis

Deficient Knowledge

Common Related Factors	Defining Characteristics
PBSC collection: unfamiliarity with mobilization and apheresis procedures Unfamiliarity with bone marrow harvest procedure, postoperative care, and recovery	Verbalized lack of knowledge or misconceptions Expressed need for information Multiple questions Increased anxiety
Common Expected Outcome Patient or significant others verbalize understanding of the PBSC collection or the bone marrow harvest procedure and recovery.	NOC Outcome Knowledge: Treatment Procedure NIC Interventions Teaching: Preoperative; Teaching: Procedure/Treatment

Ongoing Assessment

Actions/Interventions	Rationale
Assess the patient’s understanding of mobilization procedures for PBSC donation and collection.	This procedure is used more commonly.

Assess the patient’s understanding of bone marrow harvest procedure, postoperative care, self-care on bone marrow aspiration sites, potential complications, and marrow recovery.

Adults learn best when teaching builds on previous knowledge or experience. The patient may have prior incorrect or inaccurate knowledge from family, friends, or media.

Therapeutic Interventions

Actions/Interventions	Rationale
Instruct the patient on the following:
Bone marrow harvest preoperative care:
·     Database: laboratory values (including complete blood count, chemistry profile, blood typing, viral testing, and cytomegalovirus status), electrocardiogram, chest radiograph	These tests determine the health status of the donor prior to bone marrow collection.
·     Histocompatibility testing (human leukocyte antigen typing) for allogeneic donation	Issues of compatibility between donor and recipient tissue require extensive testing and screening.
·     Self-donation of blood	This is used as replacement transfusion during bone marrow harvest to prevent risk of transfusion-related complications (hepatitis, human immunodeficiency virus).
·     Ferrous sulfate three times daily for 7 to 10 days before bone marrow harvest	This provides iron, which is essential in the formation of hemoglobin.
Bone marrow aspiration:
·     Procedure for aspiration and the anatomical sites to be used.	Aspiration is performed in the operating room by inserting special needles into the center of the pelvis bones and aspirating the liquid marrow into syringes. Several needle insertions and aspirations (20 to 30) are required to collect the desired amount of marrow stem cells. The procedure lasts 1 to 2 hours.
·     Amount of bone marrow to be harvested	About 500 to 1000 mL, depending on the number of marrow stem cells needed for engraftment. This is determined by the recipient’s body size, the concentration of bone marrow cells, and the type of donor. The aspirated marrow volume is replenished by the donor in about 2 to 3 weeks.
Processing of bone marrow:
·     Filtering of aspirated marrow to remove fat and bone particles	Pulmonary complications from fat emboli are a potential complication for the recipient after transplantation.
·     Collection of marrow stem cells into standard blood administration bags or processing and cryopreservation of bone marrow cells if donation is autologous.	This is used for further processing or for intravenous infusion into the recipient.
Postoperative care:
·     Hold pressure for 5 to 10 minutes at the site; if oozing is still visible, repeat.
·     Instruct the patient to lie on the site to maintain pressure.
·     Transfer from operating room to recovery room until the patient recovers from anesthesia	The patient’s neurological and cardiopulmonary status needs to be carefully monitored during recovery from anesthesia.
·     Arrangement for same-day discharge or transfer to nursing unit if further observation is indicated	Most patients can be discharged soon after recovery, on the same day as donation.
Potential complications:
·     Anesthesia-related complications	These complications include respiratory and neurological problems.
·     Bleeding from aspiration sites	Blood loss can lead to anemia and hypovolemia.
·     Pain at aspiration site	Tenderness is expected, but severe pain may indicate hematoma formation or infection.
·     Paresthesia (tingling or sharp pain radiating from the posterior iliac crest to the thigh and/or calf)	This is caused by needle irritation or injury to the sacral nerve plexus during aspirations.
Site care:
·     Importance of keeping puncture sites clean, dry, and dressed for 72 hours after harvest or until healed	These measures reduce the risk of infection.
·     Signs and symptoms of infection to report	The patient needs to recognize and report fever, redness, or drainage from the site.
Pain management:
·     Use of analgesics	These drugs relieve pain.
·     Avoidance of pressure against iliac crest; wearing of loose, nonrestrictive clothing	These measures promote comfort.
·     Use of shoes with low heels (e.g., sandals, tennis shoes)	Flat heels prevent “foot shock” (sensation of dull or sharp “ache” radiating from heel to pelvic bone).
Anemia:
·     Continuation of iron tablets three times daily for 2 weeks after bone marrow harvest.	This supplement is taken to restore normal hemoglobin and hematocrit.
·     Transfusion of prior-donated autologous red blood cells	This measure is used to treat severe anemia.
Instruct the patient on PBSC collection: ·     For an autologous donor, chemotherapy and growth factors are administered before collection to stimulate increased production of stem cells (mobilization); in allogeneic donors, growth factors only are used for mobilization. ·     Blood is removed through a large-bore catheter and run through an apheresis machine to remove stem cells. The remaining blood is returned to the patient. ·     The procedure is performed in an outpatient setting over 2 to 4 hours for several days. ·     Collected stem cells are preserved in a manner similar to cells harvested from bone marrow.	Stem cells must be stimulated to move from the bone marrow into the bloodstream so they can be collected via apheresis. Autologous donors often receive chemotherapy as part of the mobilization protocol because they can benefit from the anti-tumor effect. Allogenic donors should not receive chemotherapy; stem cells are mobilized with growth factors alone.
Activity:
·     Return to all activities as tolerated.	Within a few weeks, the donor’s body will have replenished the donated marrow.

Nursing Diagnosis

Fear

Common Related Factors	Defining Characteristics
Impending surgery or apheresis procedure Threat of anesthesia Anticipated pain Feelings about HSC recipient (if allogenic recipient) Responsibility of being a donor Fear of the unknown Fear of injections (needed for administration of growth factors)	Increased questioning Restlessness Tense appearance Uncertainty Jitteriness Apprehension
Common Expected Outcomes Patient verbalizes reduction in fear. Patient verbalizes ability to cope. Patient expresses willingness, commitment, and positive feelings about being a donor.	NOC Outcome Anxiety Self-Control NIC Intervention Anxiety Reduction

Ongoing Assessment

Actions/Interventions	Rationale
Determine what the patient is most fearful of.	This helps guide the treatment plan.
Assess the patient’s relationship with the recipient and the circumstances under which the patient became a stem cell donor.	The patient may feel “obligated” or “pressured” to donate HSCs, especially when it is the only tissue “match” suitable for transplantation.

Therapeutic Interventions

Actions/Interventions	Rationale
Acknowledge your awareness of the patient’s fear.	This validates the feelings that the patient is having and communicates acceptance of these feelings.
Encourage verbalization of feelings, especially about the donor's role, if appropriate.	Donors may feel they are a “last resort” and that the recipient’s fate rests with them.
Assist the patient in identifying strategies used to deal with fear in the past that were helpful or comforting.	This helps the patient focus on his or her fear as being a natural part of life and something that can continue to be dealt with successfully.
Provide environment of confidence and reassurance.

Nursing Diagnosis

Risk for Infection

Common Risk Factor
Bone marrow harvest: Interruption of skin and bone integrity secondary to bone marrow aspirations
Common Expected Outcome Patient is free of infection, as evidenced by normal temperature and lack of drainage from puncture sites, or by lack of signs and symptoms of infection from the central venous catheter.	NOC Outcomes Infection Status; Bone Healing NIC Intervention Wound Care

Ongoing Assessment

Actions/Interventions	Rationale
Observe or encourage the patient to observe the puncture sites during dressing change for evidence of infection: redness, tenderness, warmth, swelling; drainage from skin puncture sites; persisting or increasing pain at the operative site or surrounding area; elevated body temperature.	Osteomyelitis is a possible complication of bone marrow aspiration. Bone marrow donors can also get cutaneous infections if the puncture sites are not properly cared for.
Instruct the patient to report first signs of infection.	Early assessment facilitates prompt treatment.
While the patient is hospitalized, obtain culture, if ordered, before the wound is cleansed.	This is required to obtain a true sample of microorganisms present.

Therapeutic Interventions

Actions/Interventions	Rationale
Change or instruct the patient to change the postoperative pressure dressing the day after harvest.	Moist dressings can harbor pathogens. Pressure dressings should remain in place for 24 hours to reduce the incidence of bleeding and hematoma formation.
Instruct the patient to use clean technique when performing daily dressing changes: wipe over each skin puncture site with prescribed antiseptic; let dry; apply small amount of antiseptic ointment to each puncture site; cover with sterile adhesive bandage; keep dressings dry and intact.	This technique reduces the risk of infection.