Hematologic cancers arise from blood-forming or immune cells. Nursing care centers on the consequences of bone marrow failure (infection, bleeding, anemia), the toxicity of treatment, and oncologic emergencies.

Leukemia — malignant white blood cell precursors multiply in the bone marrow, crowd out normal cells, and spill into the blood. Result: anemia (fatigue), neutropenia (infection — the leading cause of death), and thrombocytopenia (bleeding), even when the total WBC count is high.

Risk factors: ionizing radiation, benzene, prior chemotherapy, smoking (AML), Down syndrome and other genetic conditions.

Lymphoma — cancer of lymphocytes, usually beginning in lymph nodes.

• Hodgkin lymphoma — Reed–Sternberg cells; painless enlarged lymph node (often cervical or supraclavicular) spreading to neighboring node groups in order; peaks in young adults and older adults; associated with Epstein–Barr virus; highly curable
• Non-Hodgkin lymphoma (NHL) — a large, varied group; spreads unpredictably and often outside nodes. Diffuse large B-cell lymphoma (DLBCL) is the most common aggressive type

Multiple myeloma — cancer of plasma cells in the marrow producing an abnormal monoclonal protein (M-protein). Plasma cells activate osteoclasts, causing lytic bone lesions. Remember CRAB: hyperCalcemia, Renal impairment, Anemia, Bone lesions.

Leukemia

• Fatigue, pallor, dyspnea (anemia)
• Fever and frequent infections (neutropenia)
• Bleeding: petechiae, bruising, nosebleeds, gum bleeding (thrombocytopenia)
• Bone pain, lymphadenopathy, splenomegaly, hepatomegaly
• ALL: headache, vomiting, cranial nerve signs (CNS involvement)
• CLL: often none at diagnosis

Lymphoma

• Painless, rubbery lymph node enlargement
• B symptoms: fever above 38 °C (100.4 °F), drenching night sweats, weight loss of more than 10% in 6 months
• Pruritus (Hodgkin); cough or dyspnea from a mediastinal mass; superior vena cava obstruction (facial swelling, distended neck veins)

Multiple myeloma

• Bone pain (back, ribs, pelvis) — the most common presenting symptom — and pathologic fractures
• Hypercalcemia (confusion, thirst, constipation, polyuria), kidney injury, anemia, recurrent infections, spinal cord compression (back pain, leg weakness)

Principles: combination chemotherapy in phases (induction → consolidation → maintenance for ALL), targeted drugs, immunotherapy, radiation, and hematopoietic stem cell transplant (HSCT).

Drug safety

Listed in priority order.

1. Febrile neutropenia is an emergency. Neutropenia: absolute neutrophil count (ANC) below 500/µL (0.5 × 10⁹/L), or expected to fall below 500 within 48 hours. Fever of 38.3 °C (101 °F) once or 38.0 °C (100.4 °F) sustained for 1 hour → obtain blood cultures and give broad-spectrum IV antibiotics within 60 minutes. Fever may be the only sign
2. Infection prevention — hand hygiene is most important; private room when profoundly neutropenic; avoid sick visitors; no rectal temperatures, suppositories, or enemas; meticulous central line and mouth care; safe food handling
3. Respiratory symptoms in prolonged neutropenia — fever with dyspnea and new lung infiltrates after AML chemotherapy suggests invasive fungal infection (e.g., aspergillosis); report immediately
4. Infusion reactions — for flushing, dyspnea, or hypotension during rituximab, stop the infusion immediately, keep the IV line open, stay with the client, notify the provider, and give emergency medications per protocol
5. Bleeding precautions (platelets below about 50,000/µL, strict below 20,000/µL) — soft toothbrush, electric razor, avoid IM injections and invasive procedures, no aspirin or NSAIDs, fall prevention; prophylactic platelet transfusion usually below 10,000/µL in stable clients (higher before procedures or with bleeding or fever)
6. Tumor lysis syndrome — aggressive hydration, allopurinol or rasburicase (contraindicated in G6PD deficiency), strict intake and output, ECG monitoring. Watch for hyperkalemia, hyperphosphatemia, hypocalcemia (secondary to high phosphate), and hyperuricemia leading to acute kidney injury; do not add potassium to IV fluids; treat hypocalcemia only if symptomatic
7. Myeloma care — encourage fluids (about 2–3 L/day unless restricted) to protect the kidneys; avoid NSAIDs and unnecessary contrast; careful handling and fall prevention; encourage safe weight-bearing activity; watch for hypercalcemia and spinal cord compression
8. Chemotherapy safety — verify vesicant administration, check blood return, stop immediately for extravasation; safe handling of hazardous drugs; antiemetics before chemotherapy
9. Psychosocial support, fatigue, nutrition, and fertility counseling before treatment

• Take temperature daily and whenever feeling unwell; report 38.0 °C (100.4 °F) or higher immediately — do not wait, and do not take fever-reducing drugs before calling (they can mask fever); avoid rectal thermometers and suppositories
• Wash hands often; avoid crowds and people who are sick; ask about recommended inactivated vaccines — avoid live vaccines during treatment
• Avoid aspirin and NSAIDs; use a soft toothbrush; report nosebleeds, gum bleeding, black stools, or blood in urine
• Food safety: wash produce, cook meat and eggs thoroughly, avoid unpasteurized products
• CML: take TKIs daily exactly as prescribed; do not stop on your own; report swelling or rapid weight gain
• Report mouth sores, cough, shortness of breath, numbness or tingling, severe constipation
• Lenalidomide and many chemotherapy drugs: use reliable contraception
• Myeloma: drink fluids; report new back pain, leg weakness, or confusion
• Follow-up is lifelong for late effects (heart, lungs, secondary cancers)

• Leukemia → anemia, infection, bleeding from marrow crowding
• Febrile neutropenia: cultures and antibiotics within 60 minutes
• CML = Philadelphia chromosome (BCR-ABL) → TKIs (imatinib)
• CLL: asymptomatic early disease → watchful waiting
• APL: DIC risk; treated with ATRA + arsenic trioxide; watch differentiation syndrome
• ALL: CNS prophylaxis with intrathecal chemotherapy
• Hodgkin: Reed–Sternberg cells, painless node, B symptoms; bleomycin → pulmonary fibrosis
• DLBCL: R-CHOP; rituximab reaction → stop infusion immediately and notify
• Doxorubicin → cardiotoxicity; vincristine → neuropathy; cyclophosphamide → hemorrhagic cystitis
• Platelets very low → no aspirin/NSAIDs, bleeding precautions
• Myeloma: CRAB; bone pain and pathologic fractures most common; hydrate
• Prolonged neutropenia + fever + lung infiltrates → suspect aspergillosis