Graft -Vs.

-Host Disease
A. Assessment Assess for the following clinical manifestations: y y y y y Fever Rush Diarrhea Nausea Jaundice

B. Pathophysiology

Graft transplantation Tissue of the body has different HLA (Human Leukocyte Antigen) to that of the donor tissue The donor tissue (eg. Bone marrow) recognizes the recipient s tissue as foreign T cells are sensitized Lymphokines are released

The transplant rejects the recipient Destruction of the recipient s tissue

Skin manifestations: maculopapular rash -generalized erythroderma -desquamation and bullae

Liver manifestation: -increased bilirubin

Gastrointestinal manifestation: -diarrhea - nausea

jaundice

Possibly death

C. Nursing diagnosis  Fear related to organ rejection and threat of death.  Ineffective family coping related to situational crises.  Knowledge deficit related to prognosis and therapeutic regimen.  Risk for injury related to Graft-Vs- Host disease (GVHD).  Risk for infection related to medically induced immunosuppression. D. Management 1. Assess client s or significant others knowledge of GVHD. RATIONALE: the client or significant others also can monitor for clinical manifestations and by reporting them early enhance treatment. 2. Assess for manifestations of GVHD at day 25 post-transplant. RATIONALE: the median onset time of GVHD is 25 days after bone marrow transplant. 3. Determine baseline status or skin condition, liver function, or gastrointestinal function before donor marrow infusion. RATIONALE: Baseline data guide assessments of further data. 4. Monitor renal function daily. RATIONALE: bilirubin levels rise in GVHD. 5. Monitor magnesium levels daily. RATIONALE: Cyclosporine can induce seizures in hypomagnesemic client s. 6. Monitor characteristics of stools. If diarrhea develops keep the client on NPO. Administer anti-diarrheal agents, and test all stools for blood. RATIONALE: Diarrhea is a manifestation of GVHD. Blood loss through stool may require transfusion for replacement. 7. Monitor intake and output strictly, and record daily weights. RATIONALE: GVHD can lead to dehydration. Clients receiving chemotherapeutic agents need ample fluids during administration to prevent renal damage. 8. Irradiate all blood products before infusing. RATIONALE: Irradiation prevents the infusion of immunocompetent T lymphocytes. 9. Bathe daily in warm saline or warm Hibiciens solution diluted to 1:8 with sterile water. Pat skin dry. RATIONALE: Skin care is important to reduce the risk of infection and avoid injury to the skin. 10. Teach client or Significant others about the early manifestations of GVHD and to report them. RATIONALE: Client is ambulatory and may not recognize the need to report these data to the nurse. 11. Administer prescribed preventive agents. RATIONALE: Medications as Methotrexate and Cyclosporine are used to suppress response. 12. Apply prescribed lotions to the moist skin after bathing. RATIONALE: Keeping the skin moist reduces the risk of cracks, which increase the risk of infection.

Hypersensitivity Pneumonitis
A. Assessment Assess for the following clinical manifestations: y Adventitious sounds during auscultations. y Persistent productive cough y DOB y Fever y Fatigue B. Pathophysiology

Inhalation of organic antigens of fungal, bacterial, or animal origin. The body recognizes the antigens as foreign to the body Chemical mediators are released.

Increased blood flow

chemotaxis

Increased vascular permeability

Increased numbers of WBCs and chemical mediators especially at the site

M.O are contained, destroyed and Phagocytized.

Lung congestion and mucous production Systemic manifestations. Eg. Fever and fatigue

M.O gone

M.O remain

Persistent and productive cough

additional mediators
Difficulty of breathing

activated.

Decreased O2 supply

C. Nursing Diagnoses  Ineffective airway clearance related to edema formation and increased sputum production.  Impaired gas exchange related to alveolar- capillary membrane changes (inflammatory effects.)  Activity intolerance related to imbalance between oxygen supply and demand.  Acute pain related to persistent cough.  Risk for imbalanced nutrition: less than body requirements related to increased metabolic needs secondary to fever and infectious process. D. Management 1. Assess breath sounds before and after coughing RATIONALE: This helps in evaluation of coughing effectiveness. 2. Place the client in Semi-fowler s position. RATIONALE: The upright position enhances lung expansion and facilitates ventilation with minimal efforts. 3. Instruct the client to take a deep breath slowly and to hold it for 3-5 secs, then, exhale; to take a second breath and then, while exhaling, to cough forcefully twice. RATIONALE: Coughing helps move tracheobronchial secretions out of the lungs. Deep breathing dilates the airways, stimulates surfactants production, and epands lung tissue. 4. Help the client cough and deep breathe atleast 1-2 hours. RATIONALE: Increasing the volume of air in lungs promotes expulsion of secretions. 5. Offer sips of warm water. RATIONALE: warm water can aid relaxation and produce more effective coughing. 6. Maintain adequate level of hydration and adequate humidity of inspired air. RATIONALE: Fluids and moisture help thin secretions, making them easier to expectorate. 7. Evaluate the need for suctioning. RATIONALE: if coughing is ineffective, suctioning may be required to remove pulmonary secretions. 8. Administer prescribed antibiotics. RATIONALE: to eliminate certain bacteria if identified. 9. Give respiratory support as needed. RATIONALE: Oxygen should be administered as ordered to ensure adequate oxygen supply to the body.

Contact Dermatitis
A. Assessment Assess for the following clinical manifestations: y Itching, burning, erythema, vesiculation, and eczema. y Weeping, crusting, drying, fissuring, and peeling. y Thickening of skin (lichenification) and pigmentation changes, if repeated reactions occur of if there is continual scratching by the patient. y Secondary bacterial invasion may occur--- prevention of normal sweating produces vesicles, itching, and inflammation. B. Pathophysiology

First exposure to cosmetic, adhesive topical medications, drug additive( such as lanolin added to lotions), or pant toxin (such as poison ivy) which all contain allergen

no reaction occur

antigens are formed and T cells are sensitized

Second exposure to same allergen

hypersensitivity reactions are triggered

release of lymphokines and other chemical mediators.

pain

erythema

itching

Vesicular lesions

C. Nursing Diagnoses  Acute pain related to inflammatory process  Impaired skin integrity related to disruption of skin surface.  Disturbed body image related to inflammatory reactions in the skin.  Knowledge deficit related to unfamiliarity with resources.  Risk for infection related to inadequate primary defense (skin barrier).

D. Management 1. Inspect the entire body for distribution pattern--- helps to narrow down possible causes, which may be irritant or allergic. 2. Obtain a detailed history including the site of the initial eruption. 3. Instruct the patient as follows: a. Identify and remove the causative agent and contribution factors.  Avoid the use of soap until healing occurs.  Avoid exposing skin to the causative agent after recovery.  Wear protective gloves (thin white cotton gloves under rubber gloves) when using soap and water. b. Topical treatment  Use cool, wet dressing 15-20 mins, 3-4 times daily for small areas of acute, vesicular dermatitis for soothing and to help stop oozing.  Cleanse away softened crusts and other debris.  Use bland, unmedicated lotion for small patches of erythema.  Apply a thin layer of cream or ointment containing one of the steroids, as directed--- usually not as beneficial when blisters are present, although some authorities feel it is helpful in these instances if used more frequently (atleast 5 times daily)  Use medicated baths at room temperature for larger areas of dermatitis. 4. Give sedatives and anti histamines if necessary to relieve itching and burning. 5. Give systemic antibiotics if secondary bacterial infection is present--- purulent exudates and systemic symptoms (fever, lymphadenopathy, etc) 6. Administer short course of systemic steroids if a more widespread and disabling condition is involved--- can shorten the course of severe disease; allays inflammation.

Sarcoidosis
A. Assessment Assess for signs and symptoms, such as : y Fatigue y Weakness y Malaise y Weight loss y Fever y Cough y Shortness of breath Use X ray results to identify granulomas. B. Pathophysiology Presence of triggering agent (may be genetic, infectious, immunologic, or toxic)

Enhanced cell-mediated immune process at the site of involvement are stimulated.

Occurrence of series of interactions between T lymphocytes and monocyte-macrophages

Pulmonary manifestations: -dry cough, SOB, chest pain, hemoptysis, pneumothorax

Formation of non-caseating (i.e having no cheesy necrotic degeneration) granulomas, which are characteristics of this disease

Systemic manifestation: - fatigues, weakness, weight loss, and fever

C. Nursing Diagnoses  Impaired gas exchange related to decreased ventilation.  Anxiety related to acute breathing difficulties and fear of suffocation.  Imbalanced nutrition: less than body requirements related to reduced appetite, decreased energy level, and dyspnea.  Disturbed sleep pattern related to difficulty of breathing.  Sexual dysfunction related to dyspnea and reduced energy.

D. Management 1. Monitor lung sounds every 4-8 hours and before and after coughing episodes RATIONALE : To determine if the condition is becoming better or worse.

2. Teach and supervise effective coughing techniques. RATIONALE: proper coughing techniques conserve energy, reduce airway collapse, and lessen client frustration. 3. Remain with the client during acute episodes of breathing difficulty, and provide care in a calm, reassuring manner. RATIONALE: Reassures the client that competent health Is available if needed. Anxiety can be contagious; remain calm. 4. Provide a quiet, calm environment. RATIONALE: Reduction of external stimuli helps promote relaxation. 5. During acute episodes, open doors and curtains and limit the number of people and unnecessary equipment in the room. Provide a fan if the client perceives a benefit from the moving air. RATIONALE: Environmental changes may lessen the client s perception of suffocations. 6. Encourage the use of breathing retraining and relaxation techniques. RATIONALE: A feeing of self-control and success in facilitating breathing helps reduce anxiety. 7. Advice the client to avoid conditions that increase oxygen demand, such as smoking, temperature extremes, excess weight, and stress. RATIONALE: These factors increase peripheral vascular resistance, which increases cardiac workload and oxygen requirements. 8. Advice the client to avoid gas-producing foods, such as beans and cabbage. RATIONALE: Gas-forming foods may cause abdominal bloating and distention and thus impair ventilation.

Colegio de Sta Lourdes of Leyte Foundation Inc College of Nursing Tabontabon, Leyte

Requirement In NCM 106