Question

The registered nurse is assigned to care for a pediatric client who is receiving immune suppressants. The registered nurse is precepting a student nurse. The registered nurse reviews the key nursing considerations that the student needs to consider in the care of this patient.

Answer 1

As the student nurse is new to the situation, explanation is neded about the action, indication and nursing management of patient receving immunosupressve agents

IMMUNO SUPRESANTS

• Immunosuppressant drugs are a class of drugs that suppress or reduce the strength of the body’s immune system
• This drug is used to  lower the body’s ability to reject a transplanted organ, such as a liver, heart or kidney
• Immunosuppressant drugs also are used to treat autoimmune diseases such as lupus.
• Immunosupressant drugs inhibit cellular /humoral or both immune response and have their major use in organ transplantation and autoimmune diseases.

Immunosupressive drugs

• Immunosuppressive drugs can be categorized according to their mechanisms of action

1. Agents that interfere with cytokine production or action
2. Agents that disrupt cell metabolism, preventing lymphocyte proliferation
3. Antibodies that block T-cell surface molecules

Agents that interfere with cytokine production or action

1.Cyclosporine

Uses

• To prevent rejection of kidney, liver, and cardiac allogeneic transplants
• used as an anti-metabolite such as mycophenolate mofetil with corticosteroids
• used in treatment of severe active rheumatoid arthritis and Xerophthalmia

Action

• Suppresses cell mediated immune reactions
• Primary chemical stimulus for increasing the number of T lymphocytes

Side effects

• Nephrotoxicity
• Hepatotoxicity Infections
• Lymphoma
• Anaphylactic reactions
• Hypertension
• Hyperlipidemia
• Hyperkalemia
• Tremor
• Glucose intolerance
• Gum hyperplasia

2.Tacrolimus

• It is used for the prevention of rejection of liver and kidney transplants
• may be administered orally or IV

Adverse effects

• Nephrotoxicity

• Neurotoxicity (tremor, seizures, and hallucinations)

• Posttransplant insulin-dependent diabetes mellitus

• Anaphylactoid reactions to the injection

3. Sirolimus

• Uses in renal transplantation

• It Can be used together with cyclosporine and corticosteroids, allowing lower doses

• The combination of sirolimus and cyclosporine is synergistic because sirolimus works later in the immune activation cascade

• Itis available as an oral solution or tablet.

Adverse effects

• Hyperlipidemia

• Nephrotoxicity

• Leukopenia

• Thrombocytopenia

• Impaired wound healing

4. Azathioprine

• It is  prodrug that is converted first to 6-mercaptopurine (6-MP) and then to the nucleotide, thioinosinic acid

• Rapid proliferation is important for the immune response which depends on the de novo synthesis of purines required for cell division, for lymphocytes in particular

sideeffects

• Bone marrow suppression

5.Mycophenolate mofetil

• Used in heart kidney and liver transplants

• Rapidly hydrolyzed in the GI tract to mycophenolic acid a potent inhibitor of inosine monophosphate dehydrogenase, which blocks the formation of guanosine phosphate

• depriving the rapidly proliferating T and B cells of a key component of nucleic acids

Adverse effects

• Diarrhea
• nausea, vomiting, abdominal pain
• Leukopenia
• Anemia

6. Corticosteroids

• These are the first pharmacologic agents to be used as immunosuppressives, both in transplantation and in various autoimmune disorders.

• For transplantation,used agents are prednisone and methylprednisolone,

• In case of autoimmune conditions prednisone and prednisolone is used

adverse effects.

• they are diabetogenic and can with prolonged use

• hypercholesterolemia,

• cataracts,

• osteoporosis,

• hypertension

NURSING MANAGEMENT

Depending up on the condition of patient, considering it as a case of organ trannsplant or autoimmune dises nurse have to act

• teach the nurse student , before administering the medication assessment should be done including,

a) Before the procedure or immunosuppression therapy

• Check vital signs, and observe for any raise in temperature
• Assess for contraindications or cautions including history of allergies ,renal and hepatic impairment, history of neoplasms.This will help to avoid side effects
• Do prior physical assessment to assess for any potential adverse effects.
• Look for presence of skin lesions
• Obtain weight to monitor for fluid retention.
• Do neurological assessment
• Monitor laboratory tests for CBC and liver and renal functions tests it will help to maintain possible dose adjustment and to identify changes in bone marrow function.

b) During the therapy

• After assessing the patients general conditios, and obtaining history of potent allergic reactions to drug assemble all the articles near to patients unit
• Administer drug as indicated
• explain the procedure to the parents to get their co operation
• Protect the patient from exposure to infections and maintain strict aseptic technique for any invasive procedures to prevent infections during immunosuppression.
• Arrange for supportive care and comfort measures to decrease patient discomfort and increase therapeutic compliance.
• Observe for adverse reactions
• Provide parent education about drug effects and warning signs to increase compliance with drug.

After the procedure

• Check vital signs
• Moniter for adverse reaction
• Provide health education to the parents about drug therapy