# A nurse is caring for a patient who received an allogeneic hematopoietic stem cell transplant 21 days ago. Which assessment finding would be the highest priority concern requiring immediate intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540664 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a patient who received an allogeneic hematopoietic stem cell transplant 21 days ago. Which assessment finding would be the highest priority concern requiring immediate intervention? ## 보기 1. Temperature of 100.2°F (37.9°C) with mild fatigue 2. Platelet count of 25,000/μL with petechiae on arms 3. New onset skin rash with diarrhea and elevated liver enzymes **✔ 정답** 4. White blood cell count of 1,200/μL with neutropenia **정답: 3** ## 해설 New rash with diarrhea and elevated liver enzymes indicates acute GVHD, a life-threatening complication requiring immediate immunosuppressive therapy. Other findings are less urgent. ## 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 Graft-Versus-Host Disease (aGVHD) Assessment Clinical Context This patient is 21 days post allogeneic HSCT, a peak period for acute GVHD. While fever and cytopenias are common and require management, the classic triad of skin, GI, and liver involvement is a medical emergency. Rapid recognition and intervention are critical to prevent irreversible organ damage and high mortality. Priority Assessment Findings - Skin: Maculopapular rash, often starting on palms and soles, may become generalized and bullous. - GI Tract: Profuse, watery, greenish diarrhea; nausea, vomiting, anorexia, and severe abdominal cramping. - Liver: Cholestatic jaundice with elevated bilirubin, alkaline phosphatase, and transaminases. Immediate Nursing Actions - Notify the Provider Immediately: Report the triad of symptoms (rash, diarrhea, elevated liver enzymes) as a potential aGVHD emergency. - Prepare for Diagnostic Confirmation: Anticipate orders for a skin or GI biopsy to confirm histological diagnosis. - Initiate Supportive Care: Strict infection prevention (neutropenic precautions), meticulous skin care to prevent breakdown, accurate intake and output monitoring, and aggressive fluid/electrolyte replacement for diarrhea. - Administer First-Line Therapy: Prepare to administer high-dose systemic corticosteroids (e.g., methylprednisolone) as prescribed to suppress the donor T-cell response. - Manage Symptoms: Provide anti-diarrheal agents, pain management, and nutritional support (often total parenteral nutrition) as ordered. Differential Considerations While fever may suggest infection and thrombocytopenia indicates bleeding risk, these are secondary to the systemic, multi-organ threat of aGVHD. The combination of new skin, GI, and liver findings in an allogeneic transplant recipient is pathognomonic for aGVHD until proven otherwise and must be the highest priority for intervention. ## 핵심 개념 - **Allogeneic Hematopoietic Stem Cell Transplant (HSCT)** — A procedure where a patient receives blood-forming stem cells from a genetically similar, but not identical, donor to treat various cancers and bone marrow failure syndromes. - **Acute Graft-Versus-Host Disease (aGVHD)** — A life-threatening complication of allogeneic HSCT where donor T-cells attack the recipient's tissues, primarily affecting the skin, gastrointestinal tract, and liver. - **Engraftment** — The process by which transplanted stem cells begin to produce new blood cells in the recipient's bone marrow, typically occurring 2-4 weeks post-transplant. - **Neutropenia** — An abnormally low count of neutrophils, a type of white blood cell crucial for fighting bacterial infections, common in the post-transplant period. - **Petechiae** — Tiny, flat, red or purple spots on the skin caused by bleeding from small blood vessels, often a sign of severe thrombocytopenia. ## 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=540663) - [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._