# A nurse is caring for a patient who received an allogeneic hematopoietic stem cell transplant 14 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? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540663 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a patient who received an allogeneic hematopoietic stem cell transplant 14 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 immunosuppressive therapy and monitor for infection **✔ 정답** 2. Increase fluid intake and provide electrolyte replacement therapy 3. Apply topical corticosteroids to the affected skin areas 4. Implement strict isolation precautions and limit visitor access **정답: 1** ## 해설 Acute GVHD with skin, GI, and liver involvement is life-threatening and requires immediate immunosuppressive therapy to prevent organ damage. Other options are supportive but secondary. ## 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: Acute GVHD Post Allogeneic HSCT Assessment & Recognition Suspect acute graft-versus-host disease (aGVHD) in any allogeneic HSCT recipient presenting with the classic triad of skin rash (often maculopapular, starting on palms and soles), gastrointestinal symptoms (diarrhea volume >500 mL/day, nausea, anorexia), and hepatic dysfunction (elevated ALT, AST, alkaline phosphatase, and bilirubin) typically occurring between days +10 and +30 post-transplant. Early recognition is critical as progression can lead to severe tissue damage, infection, and non-relapse mortality. Priority Nursing Intervention The immediate priority is to administer prescribed systemic immunosuppressive therapy, most commonly high-dose corticosteroids (e.g., methylprednisolone 1-2 mg/kg/day). This directly suppresses the donor T-cell mediated attack on host tissues. Concomitantly, implement strict infection prevention measures because immunosuppression increases the risk of bacterial, viral, and fungal infections. Monitor for signs of infection, including subtle changes in vital signs, as steroids can mask fever. Supportive & Collaborative Management While immunosuppression is the priority, comprehensive care requires a multi-pronged approach. Manage severe diarrhea with fluid and electrolyte replacement, parenteral nutrition if oral intake is inadequate, and anti-diarrheal agents as prescribed. Provide meticulous skin care for the rash, including topical emollients or corticosteroids to maintain skin integrity and comfort. Monitor liver function tests daily and assess for signs of hepatic failure such as jaundice, coagulopathy, or encephalopathy. Collaborate with the transplant team to assess response to therapy and adjust treatment, which may include additional agents like calcineurin inhibitors or anti-thymocyte globulin for steroid-refractory disease. ## 핵심 개념 - **Acute Graft-versus-Host Disease (aGVHD)** — A complication after allogeneic HSCT where donor T-cells attack recipient tissues, commonly affecting skin, liver, and GI tract within 100 days post-transplant. - **Allogeneic Hematopoietic Stem Cell Transplant (HSCT)** — A procedure where a patient receives blood-forming stem cells from a genetically similar, but not identical, donor. - **Maculopapular rash on palms and soles** — A flat and raised red rash on the palms and soles, a hallmark cutaneous sign of acute GVHD. - **Non-relapse Mortality (NRM)** — Death after transplant not due to the original disease but from complications like GVHD, infection, or organ failure. ## 같은 주제 문제 - [A client who underwent an allogeneic stem cell transplant two weeks ago remains in a prote…](https://mymerci.kr/pages/nclex_q.php?qn_id=540660) - [A nurse is performing a shift assessment on a client who is 14 days post-allogeneic hemato…](https://mymerci.kr/pages/nclex_q.php?qn_id=540661) - [A nurse is caring for a patient who received an allogeneic hematopoietic stem cell transpl…](https://mymerci.kr/pages/nclex_q.php?qn_id=540662) - [A nurse is caring for a patient who received an allogeneic hematopoietic stem cell transpl…](https://mymerci.kr/pages/nclex_q.php?qn_id=540664) - [A nurse is caring for a patient who received an allogeneic hematopoietic stem cell transpl…](https://mymerci.kr/pages/nclex_q.php?qn_id=540665) - [A nurse is caring for a patient who received an allogeneic hematopoietic stem cell transpl…](https://mymerci.kr/pages/nclex_q.php?qn_id=540666) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._