NURSING PROCESS FOCUS Clients Receiving Immunostimulant Therapy Assessment Potential Nursing Diagnoses

ADAMMC32_0131756656 2/28/07 1:12 AM Page 464 TEAM-B TAEM B:Desktop Folder:

■ Obtain a health history including allergies, drug history, and possible drug ■ Injury, Risk for, related to side effects of drug interactions. ■ Nutrition, Imbalanced: Less than Body Requirements, related to gastrointesti- ■ Assess a history of cytomegalovirus and any malignancies to verify need. nal upset secondary to drug ■ Obtain laboratory work including complete blood count (CBC), electrolytes, ■ Infection, Risk for, related to bone marrow suppression secondary to drug and liver enzymes. ■ Obtain weight and vital signs, especially blood pressure. ■ Assess mental alertness. Planning: Client Goals and Expected Outcomes The client will: ■ Experience increased immune system function. ■ Demonstrate an understanding of the drug’s action by accurately describing drug side effects and precautions. ■ Immediately report effects such as fever, chills, sore throat, unusual bleeding, chest pain, palpitations, dizziness, or change in mental status. ■ Demonstrate the ability to self-administer IM or subcutaneous injection. Implementation Interventions and (Rationales) Client Education/Discharge Planning

■ Monitor for leukopenia, neutropenia, thrombocytopenia, anemia, and in- Instruct client to: creased liver enzymes. (Drugs can cause bone marrow suppression and liver ■ Comply with all ordered laboratory tests. damage.) ■ Immediately report any unusual bleeding or jaundice. ■ Avoid crowds and people with infections. ■ Avoid activities that can cause bleeding or impairment of skin integrity.

■ Ensure that the drug is properly administered. (Client education of proper ad- ■ Instruct client in proper technique for self-administration of IM or subcuta- ministration helps prevent injury and promotes optimal effectiveness of drug.) neous injection.

■ Monitor vital signs. (Loss of vascular tone leading to extravasation of plasma Instruct client to: proteins and fluids into extravascular spaces may cause hypotension and ■ Monitor blood pressure and pulse every day and report any reading outside dysrhythmias.) normal limits. ■ Report any palpitations immediately.

■ Monitor for common side effects such as muscle aches, fever, weight loss, Instruct client to: anorexia, nausea or vomiting, and arthralgia. (Monitoring provides data for ■ Take medication at bedtime to reduce side effects. possible medical intervention.) ■ Perform frequent mouth care and eat small frequent meals to reduce gas- trointestinal disturbances. ■ Take acetaminophen for flulike symptoms.

■ Monitor blood glucose levels. (Blood glucose may increase in clients with ■ Instruct client to have blood glucose level checked at regular intervals. pancreatitis.)

■ Monitor for changes in mental status such as depression, confusion, fatigue, ■ Instruct client to report any mental changes, particularly depression or visual disturbances, or numbness. (Alfa interferons cause or aggravate thoughts of suicide. neuropsychiatric disorders.) Evaluation of Outcome Criteria Evaluate the effectiveness of drug therapy by confirming that client goals and expected outcomes have been met (see “Planning”). ■ The client’s laboratory studies reveal improvement in immune system status. ■ The client demonstrates an understanding of the drug’s action by accurately describing drug side effects and precautions. ■ The client verbalizes potential side effects that should be reported to the healthcare provider. ■ The client demonstrates correct procedure for self-administering IM and subcutaneous injections. See Table 32.3 for a list of drugs to which these nursing actions apply.