Stem Cell Collection Nursing Care Plans: Deficient Knowledge

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Common Related Factors

• PBSC collection: unfamiliarity with mobilization and apheresis procedures
• Unfamiliarity with bone marrow harvest procedure, postoperative care, and recovery

Defining Characteristics

• Verbalized lack of knowledge or misconceptions
• Expressed need for information
• Multiple questions
• Increased anxiety

Common Expected Outcomes

• Patient or significant others verbalize understanding of the PBSC collection or the bone marrow harvest procedure and recovery.

Assessment

1. Assess the patient’s understanding of mobilization procedures for PBSC donation and collection. This procedure is used more commonly.
2. 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.

Interventions

• 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.