Donor immune (T) cells attack host tissues, most characteristically the skin, GI tract, and liver.
Before you read
Test yourself first: 3 questions
Question 1 of 3
The nurse is assessing a newborn for Hirschsprung disease. Which finding in the first 48 hours of life is most suggestive of this disorder?
Answer: A. Failure to pass meconium within 24 to 48 hours of birth is a hallmark of Hirschsprung disease, caused by absence of ganglion cells in a segment of the distal colon. Frequent loose stools, projectile vomiting, and excessive meconium passage are not characteristic.
Question 2 of 3
A child is diagnosed with hand-foot-and-mouth disease. The nurse expects to find which characteristic lesions?
Answer: A. Hand-foot-and-mouth disease, caused by coxsackievirus, produces painful vesicular lesions in the mouth and on the palms and soles. It is usually self-limiting, and care focuses on hydration and comfort.
Question 3 of 3
A nurse is assessing a 78-year-old client. Which finding is a normal age-related change rather than a sign of disease?
Answer: A. Decreased skin elasticity and turgor is an expected aging change due to loss of subcutaneous tissue and collagen. Resting tachycardia, productive cough, and a new confusion onset are not normal aging and warrant evaluation.
Keep the streak going with more questions like these, each with a full rationale.
What is graft-versus-host disease?
It primarily targets three organs: the skin, the liver, and the GI tract. Acute GVHD typically occurs within the first 100 days, while chronic GVHD develops later. Prevention relies on immunosuppression and irradiating blood products for at-risk clients.
Key points to remember
- Donor immune (T) cells attack host tissues, most characteristically the skin, GI tract, and liver.
- Skin involvement causes a maculopapular rash that can progress to blistering; GI involvement causes profuse diarrhea, cramping, and nausea.
- Liver involvement produces jaundice and elevated bilirubin and liver enzymes.
- Acute GVHD usually appears within 100 days of transplant; chronic GVHD develops later and resembles autoimmune disease.
- Treatment and prevention rely on immunosuppressants such as corticosteroids, cyclosporine, tacrolimus, and methotrexate.
- Blood products for immunocompromised/transplant clients are irradiated and leukocyte-reduced to prevent transfusion-associated GVHD.
Signs & symptoms
- Skin → maculopapular rash, blistering
- Gut → severe diarrhea, abd pain
- Liver → jaundice, ↑ bilirubin
Nursing priorities
- Administer immunosuppressive therapy as prescribed and monitor for therapeutic and adverse effects.
- Protect the client from infection with strict aseptic/neutropenic precautions while immunosuppressed.
- Assess skin, GI (diarrhea, stool volume), and liver status; monitor fluid and electrolyte balance.
- Provide meticulous skin care and manage rash; maintain skin integrity.
- Ensure only irradiated, leukocyte-reduced blood products are given to at-risk clients.
Labs & values
Patient teaching
- Report rash, persistent diarrhea, abdominal cramping, yellowing of the skin/eyes, or fever.
- Adhere strictly to immunosuppressant therapy and do not stop abruptly.
- Practice infection-prevention measures: hand hygiene, avoiding crowds and sick contacts.
- Protect the skin from sun and trauma and follow prescribed skin care.
- Keep all follow-up appointments for monitoring of skin, liver, and GI status.
Red flags: report now
- Signs of infection or sepsis in an immunosuppressed client (fever, hypotension) are emergencies requiring immediate action.
- Severe diarrhea with dehydration/electrolyte imbalance or worsening jaundice must be reported promptly.
- Never administer non-irradiated blood products to severely immunocompromised or transplant clients.
References
Clinical references for this topic
