# A nurse is caring for a patient who received an allogeneic hematopoietic stem cell transplant 30 days ago. The patient develops a maculopapular rash on the palms and soles, persistent diarrhea (>500 mL/day), and elevated liver enzymes (ALT 180 U/L, AST 165 U/L). What is the priority nursing intervention?

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## 문제

A nurse is caring for a patient who received an allogeneic hematopoietic stem cell transplant 30 days ago. The patient develops a maculopapular rash on the palms and soles, persistent diarrhea (>500 mL/day), and elevated liver enzymes (ALT 180 U/L, AST 165 U/L). What is the priority nursing intervention?

## 보기

1. Administer prescribed antiemetics and provide comfort measures for nausea
2. Implement strict isolation precautions and monitor for signs of infection **✔ 정답**
3. Increase fluid intake and encourage high-protein diet to promote healing
4. Apply topical corticosteroids to the rash and document skin changes

**정답: 2**

## 해설

The patient shows classic signs of acute GVHD (rash, diarrhea, elevated liver enzymes). Priority intervention is strict isolation due to severe immunosuppression from GVHD and its treatment, which increases infection risk. Other options address symptoms but do not prioritize infection prevention.

## 심화 해설

Clinical Presentation Analysis

The patient is at day +14 post allogeneic hematopoietic stem cell transplant (HSCT) and presents with a classic triad: a maculopapular rash on the palms and soles, persistent diarrhea exceeding 500 mL/day, and elevated liver enzymes (ALT 180 U/L, AST 165 U/L). This constellation of symptoms affecting the skin, gastrointestinal tract, and liver is highly specific for acute graft-versus-host disease (aGVHD).

In allogeneic HSCT, donor-derived T lymphocytes recognize recipient tissues as foreign. The pathophysiology involves activation of these donor immune cells against host epithelial barriers, antigen-presenting cells, and effector lymphocytes in target organs. The skin, gut, and liver are the most commonly affected sites, and the appearance of symptoms around the second to third week post-transplant aligns with the typical engraftment and early immune reconstitution period during which aGVHD emerges.

The provided evidence underscores that outcomes after allogeneic HSCT "may be adversely affected by infections and transplant-associated complications, contributing to non-relapse mortality (NRM)" [1]. Acute GVHD is a major transplant-associated complication and a leading driver of NRM. The reference also highlights the critical role of epithelial barriers and immune interactions modulated by factors such as vitamin D during the peri-transplant period, noting that "mucosal injury, cholestasis and corticosteroid exposure" are significant clinical concerns [2]. This directly reflects the pathophysiology unfolding in this patient: the mucosal injury in the gut is causing severe diarrhea, and the cholestatic pattern of liver injury is manifesting as elevated transaminases.

Priority Intervention Rationale

The priority nursing intervention is to administer prescribed immunosuppressive therapy and monitor for infection. The cornerstone of aGVHD management is prompt escalation of immunosuppression to halt the donor T-cell attack on host tissues. Systemic corticosteroids are typically the first-line therapy. Without rapid immune modulation, aGVHD can progress to severe, steroid-refractory disease with high mortality. The digital surveillance approach discussed in the literature aims to support "earlier detection of complications and thereby help reduce NRM" [1], reinforcing the principle that early therapeutic intervention for complications like aGVHD is essential.

However, intensifying immunosuppression carries a profound risk: infection. The same reference notes that infections are a co-contributor to NRM alongside transplant-associated complications [1]. The patient is already in a severely immunocompromised state post-transplant, and adding immunosuppressive agents further blunts the ability to fight bacterial, viral, and fungal pathogens. Therefore, the nurse's simultaneous priority is meticulous monitoring for signs of infection, as the therapeutic window for controlling aGVHD is also a period of heightened vulnerability to life-threatening sepsis.

Analysis of Alternative Options

- **Option 2 (Increase fluid intake and provide electrolyte replacement therapy):** While essential supportive care for the patient's ongoing fluid losses from diarrhea, this intervention addresses a symptom rather than the underlying immunological cause. Without controlling the aGVHD-driven mucosal damage, fluid and electrolyte losses will continue unabated. Supportive care is secondary to definitive immunosuppressive therapy.

- **Option 3 (Apply topical corticosteroids to the affected skin areas):** Topical therapy may provide symptomatic relief for the rash but is insufficient for managing systemic multi-organ aGVHD involving the gut and liver. The life-threatening aspects of this presentation are the visceral organ involvement, which requires systemic, not local, treatment.

- **Option 4 (Implement strict isolation precautions and limit visitor access):** Infection prevention is a critical component of care for all post-HSCT patients and becomes even more crucial when immunosuppression is escalated. However, this is a protective measure to prevent a complication of the *treatment*. The immediate, life-saving priority is to initiate the treatment itself—immunosuppression—to stop the active disease process of aGVHD. Monitoring for infection is the direct nursing corollary to administering that therapy.

References (research sources)

- [1]Digital Surveillance After Allogeneic Hematopoietic Stem Cell Transplantation Guides Therapeutic Interventions to Reduce Non-Relapse Mortality.Research articleBischof L, Egger-Heidrich K, Schneider M, Friedrich G, Massow A, Vogelsang J, Schmidt F, Hänel M, Illmer T, Leppla L, Teynor A, de Geest S, Muelller G, Metzeler KH, Bornhäuser M, Platzbecker U, Middeke JM, Vučinić V. (2026) · DOI: 10.1111/ejh.70159

- [2]Vitamin D and Hemopoietic Stem Cell Transplantation: Clinical Guidance for GVHD Management and Post-Transplant Outcomes.Research articleFazio M, Nasso ME, Gangemi S, Bottaro A, Gammeri L, Stagno F, Allegra A. (2026) · DOI: 10.3390/cancers18060972

## 임상 시나리오

Clinical Practice Guide
When evaluating a patient with suspected acute GVHD, a comprehensive physical assessment is necessary, including: the extent and severity of skin rash (often starting like a sunburn), the amount and character of diarrhea (green, watery), abdominal pain, and signs of jaundice. Nurses should immediately report these findings to the medical team and prepare to administer prescribed immunosuppressants (steroids, cyclosporine, etc.).

Caution
This is a single-answer question, not SATA (Select All That Apply), but the trap is that you may be tempted by "symptom management" interventions. Administering antiemetics (option 1), applying topical skin steroids (option 4), and providing nutrition/hydration (option 3) are all part of GVHD management, but they are not the immediate priority over **measures that mitigate the infection risk directly threatening the patient's life**.

## 핵심 개념

- **Allogeneic Hematopoietic Stem Cell Transplant** — Allogeneic hematopoietic stem cell transplantation. A procedure where hematopoietic stem cells are received from another person (donor) and transplanted, used for conditions such as leukemia, lymphoma, and aplastic anemia. The main complications of allogeneic transplantation are GVHD and infection.
- **Acute Graft-versus-Host Disease** — Acute graft-versus-host disease. An immune reaction where donor T-lymphocytes attack the recipient's tissues, typically occurring within 100 days after transplantation. It mainly affects the skin, liver, and gastrointestinal tract, and develops when the recipient's immune system is severely suppressed.
- **Maculopapular Rash** — Maculopapular rash. A rash that is a mix of flat spots (macules) and raised bumps (papules). In acute GVHD, it characteristically first appears on the palms, soles, ears, and neck.
- **Neutropenic Precautions / Protective Isolation** — Neutropenic precautions / protective isolation. Measures to protect patients with severely compromised immune function from infection, which may include thorough handwashing, aseptic technique, no fresh flowers/plants, restricted visitors, and use of HEPA filters.
- **Hepatotoxicity** — Hepatotoxicity. It is a condition where damage to liver cells causes elevated liver enzyme (ALT, AST) levels. In this case, ALT 180 U/L and AST 165 U/L greatly exceed the normal range (usually ALT 7-56 U/L, AST 10-40 U/L), suggesting liver involvement due to GVHD.

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