Kim Noonan, DNP, ANP-BC, AOCN, FAAN, discusses how nurses can help patients with myeloproliferative neoplasms prevent cardiovascular and thrombotic events.
Patients with myeloproliferative neoplasms (MPNs) — a group of blood cancers that causes the bone marrow to overproducer red or white blood cells or platelets (including polycythemia vera, essential thrombocythemia and myelofibrosis) — are at a particular risk for thrombotic and cardiovascular events.
Kim Noonan, DNP, ANP-BC, AOCN, FAAN, Nursing and Patient Care Services Chief Nurse Practitioner at the Dana-Farber Cancer Institute in Boston, spoke with Oncology Nursing News about the risks faced by patients, and the ways in which nurses can help patients prevent cardiovascular and thrombotic events.
Oncology Nursing News: Are there specific risk factors for patients with blood cancers that make them particularly vulnerable to issues such as these?
Noonan: There are risk factors and some of it is really the medications that we're using. So immunomodulatory drugs can increase your chance of developing a thrombosis, and so we use prophylaxis for these people, often we put them on a drug like apixaban (Eliquis) in or Rivaroxaban (Xarelto). … So, we do prophylaxis people, but at least we put them on an aspirin, and when we do this, it is associated with a definite decrease in the amount of thromboses that we see in these patients.
Patients that also have another risk factor that directs our therapy are people that maybe are overweight. People that are not mobile are at risk as well [and] people that have had a clot before. We're always asking those questions, so we really hone in into their risk factors, but then we also put that together with (asking) what kind of medications are we using?
What are some ways that that nurses can help patients lower their risk of thrombotic and cardiovascular events?
I think when people see me, they just feel like they have to start jogging, because I'm always saying, “You got to move, you have to move, you have to move.” And it's so, so important. That person that is sedentary is really at a huge risk to the point of where if they have a sedentary lifestyle, we're thinking maybe that person needs to be on anticoagulant therapy right from the beginning, as opposed to just using an aspirin.
So, nurses can hone in on those assessment skills. But also, maybe nobody's asked (the patient) if they've ever had a clot before or if they've ever had thrombosis before a pulmonary embolus, and so maybe they're going to be the person that's going to be able to establish that connection.
In addition to encouraging movemen and asking questions about a history of clots, what other advice do you have?
To be attuned as to what the side effects are [and] what the presenting symptoms are. When we're talking about thrombosis, we're talking about a deep vein thrombosis that occurs mostly in your lower extremities but can also occur in your upper extremities. But we are also talking about pulmonary emboli, and that is when you develop a thrombosis in your lungs, and to identify those symptoms is very important.
If it is in your lower extremities, it's going to be pain at that site, or maybe you're going to have an increase in edema or swelling in one extremity. If it is a lung clot or pulmonary emboli, people present with a cascade of symptoms where maybe their heart rate is up, they're very short of breath, especially with exertion, (or) they have chest pain.
I am always thinking about thrombosis first, and then I can relax, if I have maybe another explanation for their shortness of breath, but we're always working it up, we really do due diligence to not miss some kind of thrombotic event that's going on.
MPNs have long asymptomatic periods, and patients with MPNs really have to be particularly attuned because it can be easy to miss stuff. Because of that, is it important for the nurse to be diligent in monitoring symptoms?
That is 100% correct. You don't want to miss thrombosis. Because if you have the long term, or even not long term but some of the complications of having, for example, a DVT (deep vein thrombosis), a lower extremity clot, is that you could end up with a pulmonary embolus. And it just gets worse, it doesn't get better if it goes undiagnosed. We want to stop the therapy too, as soon as we can, and we want to start medications. And sometimes people have to be hospitalized because of these events.
In addition to elevated heart rate, shortness of breath, what are some potential warning signs that patients should be looking out for?
It's really that for a pulmonary embolus, that shortness of breath. Maybe their heart rate is higher than normal. They can have a fever, just sort of an unexplained fever, (in addition to) the shortness of breath that we talked about, but also with exertion, that they're walking across the room and can't catch their breath and they don't know why. But chest pain as well, those are all the really important symptoms. Maybe your heart rate is a little irregular as well, but that's not as common.
What role do nurses play in helping mitigate risk, manage symptoms, and educate patients regarding this issue?
We try to produce educational material for people, but we're always assessing, we're always asking, we're the ones that are spending the time with the patient at the bedside, they're sort of our captive audience for a period of time.
And we can really take that time to think about what it is that we need to assess on this patient. Are you drinking enough? Are you moving around enough? Do you have any symptoms? As I said before, have you ever had a clot? And did you recently take a long ride in the car, for maybe six hours, or an airplane ride to Asia? We have a lot of patients that travel all over the world. And just getting off of a plane is, to me, pretty nerve-wracking.
Plane rides are rough enough without having to worry about that.
They are. And if we have patients that have heart disease, for example, congestive heart failure, they're at risk. And so we look at comorbidity as well. Certainly, have you had a thrombosis in the past, but do you have a cardiac history that would also increase your risk for thrombosis?