HEMATOLOGICAL DISORDERS

Bone marrow: *Description* (6)

1. Site of hematopoiesis 2. It consists of islands of cellular components *(red marrow)* separated by fat *(yellow marrow).* 3. Highly vascular w/ primitive cells called *stem cells.* 4. When stimulated to do so, stem cells can begin a process of *differentiation* into either myeloid or lymphoid stem cells 5. *Lymphoid stem cells* produce either T or B lymphocytes. 6. *Myeloid stem cells* differentiate into three broad cell types: erythrocytes, leukocytes and platelets

Circulatory overload:

1. Description: Caused by the infusion of blood at a rate too rapid for the client to tolerate 2. Assessment a. Cough, dyspnea, chest pain, and wheezing on auscultation of the lungs b. Headache c. Hypertension d. Tachycardia and a bounding pulse e. Distended neck veins 3. Interventions a. *Slow the rate of infusion; Place the client in an upright position, with the feet in a dependent position.*

Anemia symptoms

*Depend on the rapidity of the development of the anemia, duration of the anemia, metabolic requirements of the patient, concurrent problems, and concomitant features* 1. Fatigue, weakness, malaise 2. Pallor or jaundice 3. Cardiac and respiratory symptoms 4. Tongue changes 5. Nail changes 6. Angular cheilosis 7. Pica

Types of anemia

*Lower than normal hemoglobin and fewer than normal circulating erythrocytes; a sign of an underlying disorder* 1. *Hypoproliferative:* defect in production of RBCs -Caused by iron, vitamin B12, or folate deficiency, decreased erythropoietin production, cancer 2. *Hemolytic:* excess destruction of RBCs -Caused by altered erythropoiesis, or other causes such as hypersplenism, drug-induced or autoimmune processes, mechanical heart valves

Septicemia

1. Description: Occurs with the transfusion of blood that is contaminated with microorganisms 2. Assessment a. Rapid onset of chills and a high fever b. Vomiting c. Diarrhea d. Hypotension e. Shock 3. *Interventions* a. Notify the HCP. b. Obtain blood cultures and cultures of the blood bag. c. *Administer oxygen, intravenous fluids, antibiotics, vasopressors, and corticosteroids as prescribed.*

Leukemia: *Medical Interventions* (8)

1. *Chemotherapy* a. *Induction therapy* is aimed at achieving a rapid, complete remission of all manifestations of the disease. b. *Consolidation therapy* is administered early in remission with the aim of curing. c. Maintenance therapy may be prescribed for months or years following successful induction and consolidation therapy; the aim is to maintain remission. 2. Administer antibiotic, antibacterial, antiviral, and antifungal medications as prescribed. 3. Administer colony-stimulating factors as prescribed. 4. Administer blood replacements as prescribed. 5. Maintain infection and bleeding precautions. 6. Prepare the client for transplantation if indicated. 7. Instruct the client in appropriate home care measures. 8. Provide psychosocial support and support services for home care.

Acute myeloid leukemia

1. *Defect in stem cell that differentiate into all myeloid cells: monocytes, granulocytes, erythrocytes, and platelets* 2. Most common nonlymphocytic leukemia 3. Affects all ages with peak incidence at age 60 years 4. Prognosis is variable 5. *CBC shows decrease RBC and PLT* 6. Manifestations: *fever and infection, weakness and fatigue, bleeding tendencies, pain from enlarged liver or spleen, hyperplasia of gums, bone pain* 7. Treatment aggressive chemotherapy—induction therapy, BMT or PBSCT

Bone Marrow Transplantation: *Complications*

1. *Failure to engraft:* If the transplanted stem cells fail to engraft, the client will die unless another transplantation is attempted and is successful. 2. *Graft-versus-host disease in allogeneic transplants* a. Although the recipient cannot recognize the donated stem cells as foreign or non-self because of the total immunosuppression, the immune-competent cells of the donor recognize the recipient's cells as foreign and mount an immune offense against them. b. *Graft-versus-host disease* is managed cautiously with immunosuppressive agents to avoid suppressing the new immune system to such an extent that the client becomes more susceptible to infection, or the transplanted cells stop engrafting. 3. *Veno-occlusive disease* a. The disease involves occlusion of the hepatic venules by thrombosis or phlebitis. b. Signs include right upper quadrant abdominal pain, jaundice, ascites, weight gain, and hepatomegaly. c. Early detection is critical because there is no known way to open the hepatic vessels. d. The client will be treated with fluids and supportive therapy.

Leukocytes

1. *Granulocytes* -Eosinophils -Basophils -Neutrophils -Bands: left shift 2. *Agranulocytes* -Monocytes -Lymphocytes -T cells and B cells

Bone Marrow Transplantation: *Posttransplantation period*

1. *Infection, bleeding, or neutropenia and thrombocytopenia are major concerns until engraftment occurs.* 2. During the posttransplantation period, the client remains without any natural immunity until the donor stem cells begin to proliferate and engraftment occurs.

Chronic Lymphocytic Leukemia (CLL)

1. *Malignant B lymphocytes, most of which are mature, may escape apoptosis, resulting in excessive accumulation of cells* 2. *Most common form of leukemia* 3. More common in older adults, affects men more often; Survival varies from 2 to 14 years depending on stage 4. Manifestations: *lymphadenopathy (>100,000), hepatomegaly, splenomegaly; in later stages, anemias and thrombocytopenia; autoimmune complications with RES destroying RBCs and platelets may occur; B symptoms include fever, sweats, weight loss* 5. Treatment: early stage may require no treatment, chemotherapy, monoclonal antibody therapy

Acute Lymphocytic Leukemia (ALL)

1. *Uncontrolled proliferation of immature cells from lymphoid stem cell (lymphoblasts)* 2. Most common in young children, boys more often than girls 3. Prognosis is good for children; 80% 5-year event-free survival but drops with increased age 4. Manifestations: *leukemic cell infiltration is more common with this leukemia, with symptoms of meningeal involvement and liver, spleen, and bone marrow pain* 5. Treatment: chemotherapy, imatinib mesylate (if Philadelphia chromosome positive), BMT or PBSCT, monoclonal antibody therapy

BLOOD CELL: *Type and function*

1. *WBC (Leukocyte)* Fights infection 2. *Neutrophil* Essential in preventing or limiting bacterial infection via phagocytosis 3. *Monocyte *Enters tissue as macrophage; highly phagocytic, especially against fungus; immune surveillance 4. *Eosinophil* Involved in allergic reactions (neutralizes histamine); digests foreign proteins 5. *Basophil* Contains histamine; integral part of hypersensitivity reactions 6. *Lymphocyte* Integral component of immune system -*T lymphocyte* Responsible for cell-mediated immunity; recognizes material as "foreign" (surveillance system) -*B lymphocyte *Responsible for humoral immunity; many mature into plasma cells to form antibodies -*Plasma cell* Secretes immunoglobulin (Ig, antibody); most mature form of B lymphocyte 7. *RBC (Erythrocyte)* Carries hemoglobin to provide oxygen to tissues; average lifespan is 120 days 8. *Platelet (Thrombocyte)* Fragment of megakaryocyte; provides basis for coagulation to occur; maintains hemostasis; average lifespan is 10 days

Leukemia

1. *leukemias are a group of hematological malignancies involving abnormal overproduction of leukocytes, usually at an immature stage, in the bone marrow.* 2. The two major types of leukemia are *lymphocytic* (involving abnormal cells from the lymphoid pathway) and *myelocytic or myelogenous* (involving abnormal cells from the myeloid pathways). 3. Leukemia may be acute, with a sudden onset, or chronic, with a slow onset and persistent symptoms over a period of years. 4. Leukemia affects the bone marrow, causing *anemia, leukopenia, the production of immature cells, thrombocytopenia, and a decline in immunity.* 5. The cause is unknown and appears to involve genetically damaged cells, leading to the transformation of cells from a normal state to a malignant state. 6. Risk factors include genetic, viral, immunological, and environmental factors and exposure to radiation, chemicals, and medications, such as previous chemotherapy.

Types of Blood Donations: *Autologous*

1. A donation of the client's own blood before a scheduled procedure is an autologous donation; it reduces the risk of disease transmission and potential transfusion complications. 2. Autologous donation is not an option for a client with leukemia or bacteremia. 3. A donation can be made every 3 days as long as the hemoglobin remains within a safe range. 4. Donations should begin within 5 weeks of the transfusion date and end at least 3 days before the date of transfusion.

Signs of an immediate transfusion reaction (10)

1. A transfusion reaction is an adverse reaction that happens as a result of receiving a blood transfusion 2. Types of transfusion reactions include *hemolytic, allergic, febrile or bacterial reactions (septicemia), or transfusion-associated graft-versus-host disease (GVHD).* a. Chills and diaphoresis b. Muscle aches, back pain, or chest pain c. Rashes, hives, itching, and swelling d. Rapid, thready pulse e. Dyspnea, cough, or wheezing f. Pallor and cyanosis g. Apprehension h. Tingling and numbness i. Headache j. Nausea, vomiting, abdominal cramping, and diarrhea

Types of donor stem cells

1. Allogeneic: Stem cell donor is usually a sibling, parent with a similar tissue type, or a person who is not related to the client (unrelated donor). 2. Syngeneic: Stem cells are from an identical twin. 3. *Autologous* a. Autologous donation is the *most common type.* b. The client receives his or her own stem cells. c. *Stem cells are harvested during disease remission and are stored frozen to be reinfused later.*

Disseminated intravascular coagulation (DIC)

1. Altered hemostasis mechanism causes massive clotting in microcirculation. 2. As clotting factors are consumed, bleeding occurs. *Symptoms are related to tissue ischemia and bleeding.* 3. *Treatment:* treat underlying cause, correct tissue ischemia, replace fluids and electrolytes, maintain blood pressure, replace coagulation factors, use heparin *Life-threatening*

Leukemia: *assessment* (15)

1. Anorexia, fatigue, weakness, weight loss 2. Anemia 3. Overt bleeding *(nosebleeds, gum bleeding, rectal bleeding, hematuria, increased menstrual flow)* and occult bleeding (e.g., as detected in a fecal occult blood test) 4. Ecchymoses, petechiae 5. Prolonged bleeding after minor abrasions or lacerations 6. Elevated temperature 7. Enlarged lymph nodes, spleen, liver 8. Palpitations, tachycardia, orthostatic hypotension 9. Pallor and dyspnea on exertion 10. Headache 11. Bone pain and joint swelling 12. Normal, elevated, or reduced white blood cell count 13. Decreased hemoglobin and hematocrit levels 14. Decreased platelet count 15. *Positive bone marrow biopsy identifying leukemic blast-phase cells*

Leukemia Complications: *Fatigue and nutrition*

1. Assist the client in selecting a well-balanced diet. 2. Provide small, frequent meals (high calorie, high protein, high carbohydrate) that require little chewing to reduce energy expenditure at mealtimes. 3. Assist the client in self-care and mobility activities. 4. Allow adequate rest periods during care. 5. Do not perform activities unless they are essential; assist the client in scheduling important or pleasurable activities during periods of highest energy. 6. Administer blood products for anemia as prescribed.

Types of Blood Donations: *Blood salvage*

1. Blood salvage is an autologous donation that involves suctioning blood from body cavities, joint spaces, or other closed body sites. 2. Blood may need to be "washed," a special process that removes tissue debris before reinfusion.

Bone Marrow Transplantation: *Description*

1. Bone marrow transplantation (BMT) and peripheral blood stem cell transplantation (PBSCT) are procedures that replace stem cells that have been destroyed by high doses of chemotherapy and/or radiation therapy. 2. BMT and PBSCT are most commonly used in the treatment of leukemia and lymphoma, but are also used to treat other cancers, such as neuroblastoma and multiple myeloma. 3. *The goal of treatment is to rid the client of all leukemic or other malignant cells through treatment with high doses of chemotherapy and whole-body irradiation.* 4. Because these treatments are damaging to bone marrow cells, without the replacement of bloodforming stem cell function through transplantation, the client would die of infection or hemorrhage.

PRE-Administration of Blood Transfusion

1. Check the client's identity before administering a blood product. 2. *Be sure to check the Health care provider's prescription, that the client has an appropriate venous access site, that crossmatching procedures have been completed, that an informed consent has been obtained, and that the correct client is receiving the correct type of blood.*

Leukemia Complications: *Bleeding*

1. During the period of greatest bone marrow suppression (the nadir), the platelet count may be extremely low. 2. The client is at risk for bleeding when the platelet count falls below 50,000 cells/mm3, and spontaneous bleeding frequently occurs when the platelet count is lower than 20,000 cells/mm3. 3. Clients with platelet counts lower than 20,000 cells/mm3 may need a platelet transfusion. 4. For clients with anemia and fatigue, packed red blood cells may be prescribed. 5. Monitor laboratory values. 6. Examine the client for signs and symptoms of bleeding; examine all body fluids and excrement for the presence of blood. 7. Handle the client gently; use caution when taking blood pressures to prevent skin injury. 8. Monitor for signs of internal hemorrhage (e.g., pain, rapid and weak pulse, increased abdominal girth, and abdomen guarding). 9. Provide soft foods that are cool to warm to avoid oral mucosa damage. 10. Avoid injections, if possible, to prevent trauma to the skin and bleeding; apply firm and gentle pressure to a needle stick site for at least 5 minutes, or longer if needed. 11. Pad side rails and sharp corners of the bed and furniture. 12. Avoid rectal suppositories, enemas, and thermometers. 13. If the female client is menstruating, count the number of pads or tampons used. 14. Administer blood products as prescribed. 15. Instruct the client to use a soft toothbrush and avoid dental floss. 16. Instruct the client to use only an electric razor for shaving.

Types of Blood Components: *Fresh-frozen plasma*

1. Fresh-frozen plasma may be used to provide clotting factors or volume expansion; it contains no platelets. 2. Fresh-frozen plasma is infused within 2 hours of thawing, while clotting factors are still viable, and is infused over a period of 15 to 30 minutes. 3. Rh compatibility and ABO compatibility are required for the transfusion of plasma products. 4. *Evaluation of an effective response is assessed by monitoring coagulation studies, particularly the prothrombin time and the partial thromboplastin time, and resolution of hypovolemia.*

Leukemia Complications: *Infection* (28)

1. Infection can occur through autocontamination or cross-contamination. The white blood cell (WBC) count may be extremely low during the period of greatest bone marrow depression, known as the nadir. 2. Common sites of infection are the skin, respiratory tract, and gastrointestinal tract. 3. Initiate protective isolation procedures. 4. Ensure frequent and thorough hand washing by the client, family, and health care providers. 5. Staff and visitors with known infections or exposure to communicable diseases should avoid contact with the client until risk of infectious spread has passed. 6. Use strict aseptic technique for all procedures. 7. Keep supplies for the client separate from supplies for other clients; keep frequently used equipment in the room for the client's use only. 8. Limit the number of staff entering the client's room to reduce the risk of cross-infection. 9. Maintain the client in a private room with the door closed. 10. Place the client in a room with high-efficiency particulate air filtration or a laminar airflow system if possible. 11. Reduce exposure to environmental organisms by eliminating fresh or raw fruits and vegetables (low-bacteria diet) from the diet; eliminate fresh flowers and live plants from the client's room and avoid leaving standing water in the client's room. 12. Be sure that the client's room is cleaned daily. 13. Assist the client with daily bathing, using an antimicrobial soap. 14. Assist the client to perform oral hygiene frequently. 15. Initiate a bowel program to prevent constipation and prevent rectal trauma. 16. Avoid invasive procedures such as injections, insertion of rectal thermometers, and urinary catheterization. 17. Change wound dressings daily, and inspect the wounds for redness, swelling, or drainage. 18. Assess the urine for cloudiness and other characteristics of infection. 19. Assess skin and oral mucous membranes for signs of infection 20. Auscultate lung sounds, and encourage the client to cough and deep-breathe. 21. Monitor temperature, pulse, respirations, blood pressure, and for pain. 22. Monitor white blood cell and neutrophil counts. 23. Notify the HCP if signs of infection are present, and prepare to obtain specimens for culture of the blood, open lesions, urine, and sputum; chest radiograph may also be prescribed. 24. Administer prescribed antibiotic, antifungal, and antiviral medications. 25. Instruct the client to avoid crowds and those with infections. 26. Instruct the client about a low-bacteria diet. 27. Instruct the client to avoid activities that expose the client to infection, such as changing a pet's litter box or working with house plants or in the garden. 28. Instruct the client that neither they nor their household contacts should receive immunization with a live virus such as measles, mumps, rubella, polio, varicella, shingles, and some influenzas, including H1N1 vaccine *Infection is a major cause of death in the immunosuppressed client.*

Leukemia Complications: *Mouth Care for the Client with Mucositis*

1. Inspect the mouth daily. 2. Offer complete mouth care before and after every meal and at bedtime. 3. Brush the teeth and tongue with a soft-bristled toothbrush or sponges. 4. Provide mouth rinses every 12 hours with the prescribed solution. 5. Administer topical anesthetic agents to mouth sores as prescribed. 6. Avoid the use of alcohol- or glycerin-based mouthwashes or swabs because they are irritating to the mucosa. 7. Offer soft foods that are cool to warm in temperature rather than foods that are hard or spicy.

Hypoproliferative Anemias

1. Iron deficiency anemia 2. Anemia in renal disease 3. Anemia of chronic disease 4. Aplastic anemia 5. Megaloblastic anemia -Folic acid deficiency -Vitamin B12 deficiency

Administration of Blood Transfusion

1. Maintain standard and transmission-based precautions and surgical asepsis as necessary. 2. Insert an intravenous (IV) line and infuse normal saline; maintain the infusion at a keep-vein-open rate. 3. *An 18- or 19-gauge IV needle will be needed to achieve a maximum flow rate of blood products and to prevent damage to red blood cells; if a smaller gauge needle must be used, red blood cells may be diluted with normal saline* (check agency procedure). 4. A central venous catheter is an acceptable venous access option for blood transfusions; for a multilumen catheter, use the largest catheter port available or check the port size to ensure that it is adequate for blood administration. 5. Always check the bag for the volume of the blood component. 6. Blood products should be infused through administration sets designed specifically for blood; *use a Y-tubing or straight tubing blood administration set that contains a filter designed to trap fibrin clots and other debris that accumulate during blood storage* 7. Premedicate the client with acetaminophen (Tylenol) or diphenhydramine (Benadryl), as prescribed, if the client has a history of adverse reactions; if prescribed, oral medications should be administered 30 minutes before the transfusion is started, and intravenously administered medications may be given immediately before the transfusion is started. 8. Instruct the client to report anything unusual immediately. 9. Determine the rate of infusion by the HCP's prescription or, if not specified, by agency policy. 10. *Begin the transfusion slowly under close supervision; if no reaction is noted within the first 15 minutes, the flow can be increased to the prescribed rate.* 11. During the transfusion, monitor the client for signs and symptoms of a transfusion reaction; *the first 15 minutes of the transfusion are the most critical, and the nurse must stay with the client.* 12. *If a major ABO incompatibility exists or a severe allergic reaction occurs, the reaction is usually evident within the first 50 mL of the transfusion.* 13. Document the client's tolerance to the administration of the blood product. 14. Monitor appropriate laboratory values and document effectiveness of treatment related to the specific type of blood product.

Bone marrow biopsy:

1. Most patients have no discomfort after a bone marrow aspiration, but *the site of a biopsy may ache for 1 or 2 days.* 2. Warm tub baths and a mild analgesic agent (eg, acetaminophen [Tylenol]) may be useful. *Aspirin-containing analgesic agents should be avoided because they can aggravate or potentiate bleeding.*

Chronic Myeloid Leukemia (CML)

1. Mutation in myeloid stem cell with uncontrolled proliferation of cells—Philadelphia chromosome 2. Stages: chronic phase, transformational phase, blast crisis 3. Uncommon in people younger than age 20 years, with increased incidence with age; mean age: 55 to 60 years; *Life expectancy of 3 to 5 years* 3. Manifestations: *initially may be asymptomatic, malaise, anorexia, weight loss, confusion or shortness of breath caused by leukostasis (>100,000), enlarged tender spleen, or enlarged liver* 4. Treatment: imatinib mesylate (Gleevec) blocks signals in leukemic cells that express BCR-ABL protein; chemotherapy, BMT or PBSCT

Types of Blood Components: * Packed red blood cells (PRBCs)*

1. Packed red blood cells are a blood product used to replace erythrocytes; *infusion time for 1 unit is usually between 2 and 4 hours.* 2. Each unit increases the hemoglobin level by 1 g/dL and hematocrit by 3%; the change in laboratory values takes 4 to 6 hours after completion of the blood transfusion. 3. *Evaluation of an effective response is based on the resolution of the symptoms of anemia and an increase in the erythrocyte, hemoglobin, and hematocrit count.* *Washed red blood cells (depleted of plasma, platelets, and leukocytes) may be prescribed for a client with a history of allergic transfusion reactions or those who underwent hematopoietic stem cell transplant.*

Types of Blood Components: *Platelet transfusion* (5)

1. Platelets are used to treat thrombocytopenia and platelet dysfunctions. 2. Crossmatching is not required but usually is done (platelet concentrates contain few red blood cells). 3. The volume in a unit of platelets may vary; always check the bag for the volume of the blood component (in milliliters). 4. *Platelets are administered immediately upon receipt from the blood bank and are given rapidly, usually over 15 to 30 minutes.* 5. *Evaluation of an effective response is based on improvement in the platelet count, and platelet counts normally are evaluated 1 hour and 18 to 24 hours after the transfusion; for each unit of platelets administered, an increase of 5000 to 10,000 cells/mm3 is expected.*

Actions to Take in the Care of a Client Experiencing a Transfusion Reaction:

1. Stop the transfusion. 2. Change the intravenous (IV) tubing down to the IV site and keep the IV line open with normal saline. 3. Notify the health care provider (HCP) and blood bank. 4. Stay with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes. 5. Prepare to administer emergency medications as prescribed. 6. Obtain a urine specimen for laboratory studies (perform any other laboratory studies as prescribed). 7. Return blood bag, tubing, attached labels, and transfusion record to the blood bank. 8. Document the occurrence, actions taken, and the client's response.

Bone Marrow Transplantation: Procedure *3. Transplantation/ 4. Engraftment*

3. *Transplantation:* a. Stem cells are administered through the client's central line in a manner similar to that for a blood transfusion. b. Stem cells may be administered by IV infusion or by IV push directly into the central line. 4. *Engraftment* a. The transfused stem cells move to the marrow-forming sites of the recipient's bones. b. Engraftment occurs when the white blood cell, erythrocyte, and platelet counts begin to rise. c. *When successful, the engraftment process takes 2 to 5 weeks.*

leukemia manifestations: ANT

A-anemia N-neutropenia T-thrombocytopenia

Compatibility

A. *Client (the recipient) blood samples are drawn and labeled at the client's bedside at the time the blood samples are drawn; the client is asked to state his or her name, which is compared with the name on the client's identification band or bracelet.* B. The recipient's ABO type and Rh type are identified. C. An antibody screen is done to determine the presence of antibodies other than anti-A and anti-B. D. To determine compatibility, crossmatching is done, in which donor red blood cells are combined with the recipient's serum and Coombs' serum; *the crossmatch is compatible if no red blood cell agglutination occurs.* E. *The universal red blood cell donor is O negative; the universal recipient is AB positive.* F. *Clients with Rh-positive blood can receive RBC transfusion from an Rh-negative donor if necessary; however, an Rh-negative client should not receive Rh-positive blood.* *The donor's blood and the recipient's blood must be tested for compatibility. If the blood is not compatible, a life-threatening transfusion reaction can occur.*

Anemia: *Medical Management*

Correct or control the cause Transfusion of packed RBCs Treatment specific to the type of anemia Dietary therapy Iron or vitamin supplementation: iron, folate, B12 Transfusions Immunosuppressive therapy

Neutropenia

Decreased production or increased destruction of neutrophils (<2,000/mm3)

Anemia diagnostic labs

Hemoglobin and hematocrit Reticulocyte count RBC indices Iron studies Vitamin B12 Folate Bone marrow aspiration

Leukemia: *complications*

Infection Bleeding Renal dysfunction Tumor lysis syndrome Nutritional depletion Mucositis Depression

Hemolytic anemias:

Sickle cell anemia Thalassemia Glucose-6-phosphate dehydrogenase deficiency Immune hemolytic anemia Hereditary hemochromatosis

Erythropoiesis

The blood and the blood forming sites, including the bone marrow and the reticuloendothelial system (RES)

Bone Marrow Transplantation: Procedure: *1. Harvest*

a. The stem cells used in *PBSCT* come from the bloodstream in a 4- to 6-hour process called *apheresis or leukapheresis:* -the blood is removed through a central venous catheter and an apheresis machine removes the stem cells and returns the remainder of the blood to the donor. b. In *BMT,* marrow is harvested through multiple aspirations from the iliac crest to retrieve sufficient bone marrow for the transplant. c. Marrow from the client is filtered for residual cancer cells. d. Allogeneic marrow is transfused immediately; autologous marrow is frozen for later use *(cryopreservation).* e. Harvesting is done before the initiation of the conditioning regimen.

Bone Marrow Transplantation: Procedure *2. Conditioning*

refers to an *immunosuppression therapy regimen* used to eradicate all malignant cells, provide a state of immunosuppression, and create space in the bone marrow for the engraftment of the new marrow.