About
Activation of donor cells ( T lymphocytes) in transplant clients causing an immune response that attacks client's healthy tissue and cells.
Assess
Fever, diffuse rash, progressive blistering and peeling, nausea, vomiting, diarrhea, abdominal pain, hepatomegaly, jaundice, biliary stasis, elevated liver enzymes
Complications
Liver failure, blisters, rash, jaundice, death
Diagnosis
- Risk for infection related to immunodeficiency.
- Impaired skin integrity related to impaired immune defenses.
- Risk for injury related to impaired immune defenses.
- Fluid volume deficit related to large fluid losses
- Fear related to threat of death.
Goals
- The client will remain free from infection.
- The client will have adequate fluid volume balance.
- The client will have a decrease in diarrhea.
- The client will have a decrease in itching and pain.
Interventions
- Assess skin, liver enzymes, strict intake and output, electrolytes.
- Monitor itching, pain, redness, skin integrity, vitals, diarrhea characteristics.
- Replace fluids with intravenous solutions.
- Administer anti-diarrheal, anti-itching drugs, immunosuppressants as indicated by physician.
- Protect client from infection.
- Administer irradiated blood products in clients at high risk of GVHD.
- Teach client signs and symptoms necessitating immediate intervention.
- Encourage client to express fears and concerns related to complication.
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