8/8/2019 Immunosuppressant

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Assessment Potential Nursing Diagnoses

Obtain a health history including allergies, drug history, and possible druginteractions.

Assess for presence of metastatic cancer, active infection, renal or liver dis-ease, and pregnancy.

Assess skin integrity; specifically look for lesions and skin color.

Obtain results of laboratory work including complete blood count (CBC), elec-trolytes, and liver enzymes.

Obtain vital signs, especially temperature and blood pressure.

Infection, Risk for, related to depressed immune response secondary to drug

Injury, Risk for, related to thrombocytopenia secondary to drug

Planning: Client Goals and Expected Outcomes

The client will:

Experience no symptoms of organ or allograft rejection. Immediately report elevated temperature, unusual bleeding, sore throat, mouth ulcers, and fatigue to healthcare provider.

Demonstrate an understanding of the drugs action by accurately describing drug side effects and precautions.

Implementation

Interventions and (Rationales)

Assess renal function. (Drugs cause nephrotoxicity in many clients because of

physiological changes in the kidneys such as microcalcifications and interstitialfibrosis.)

Monitor liver function tests. (Drugs increase the risk for liver toxicity.)

Advise client to:

Keep accurate record of urine output. Report significant reduction in urine flow.

Instruct client about the importance of regular laboratory testing.

NURSING PROCESS FOCUS Clients Receiving Immunosuppressant Therapy

Client Education/Discharge Planning

Watch for signs and symptoms of infection, including elevated temperature.(There is an increased risk of infection owing to immune suppression.)

Monitor vital signs, especially temperature and blood pressure. (Drugs maycause hypertension, especially in clients with kidney transplants.)

Monitor for hirsutism, leukopenia, gingival hyperplasia, gynecomastia, sinusi-tis, and hyperkalemia. (These are common side effects.)

Avoid permitting client to ingest grapefruit juice. (Grapefruit juice increasescyclosporine levels 50% to 200%.)

Assess nutritional status. (Drugs may cause weight gain.)

Instruct client to:

Wash hands thoroughly and frequently.

Avoid crowds and people with infection.

Teach client to: Monitor blood pressure and temperature, ensuring proper use of home equipment.

Keep all appointments with healthcare provider.

Advise client to:

See a dentist on a regular basis.

Comply with regular laboratory assessments (CBC, electrolytes, and hormonelevels).

Instruct client to: Avoid drinking grapefruit juice.

Take medication with food to decrease GI upset.

Instruct client regarding a healthy diet that avoids excessive fats and sugars.

Evaluation of Outcome Criteria

Evaluate the effectiveness of drug therapy by confirming that client goals and expected outcomes have been met (see Planning):

The client is free of signs of infecton or organ rejection. The client accurately states signs and symptoms to be reported to the healthcare provider.

The client demonstrates an understanding of the drugs action by accurately describing drug side effects and precautions.

See Table 32.4 for a list of drugs to which these nursing actions apply.