McKenna's Pharmacology for Nursing, 2e

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C H A P T E R 1 7  Immune modulators

DISCUSSION T.B.’s medical regimen will include a very complicated combination of rehabilitation, nutrition, drug therapy and prevention. T.B. should know the risks of transplant rejection and the measures that will be used to prevent it. He also should know the names of his medications and when to take them, the signs and symptoms of rejection to watch for, and what to do if they occur. T.B. must understand the need to prevent exposure to infections and the precautions required, such as avoiding crowded areas and people with known diseases, avoiding injury, and taking steps to maintain cleanliness and avoid infection if an injury occurs. The medications that T.B. is taking may cause him to experience flu-like symptoms, which can be quite unpleasant. A restful, quiet environment may help to decrease his stress. Paracetamol may be ordered to help alleviate the fever, aches and pains. T.B. also may experience gastrointestinal upset, nausea and vomiting related to drug effects. A nutritional consultation may be requested to help T.B. maintain a good nutritional state. Frequent mouth care and small, frequent meals may help. Proper nutrition will help T.B. to recover, heal and maintain his health. T.B.’s primary healthcare provider will need to work with the transplantation surgeon, rehabilitation team, dietician and cardiologist to coordinate a total program that will help T.B. to avoid problems and make the most of his transplanted heart. CARE GUIDE FOR T.B.: CYCLOSPORIN, MYCOPHENOLATE AND CORTICOSTEROIDS Assessment: History and examination • Assess for history of allergies to any immune suppressant, renal or hepatic impairment, history of neoplasm, concurrent use of cholestyramine, theophylline, phenytoin, other nephrotoxic drugs, digoxin, statins, diltiazem, metoclopramide, amiodarone, androgens, azole anti – fungals, macrolides; grapefruit juice • Review physical examination findings, including orientation, reflexes, affect (neurological); temperature and weight (general); pulse, cardiac auscultation, blood pressure, oedema, electrocardiogram (cardiovascular); liver evaluation (GI); and laboratory test results (FBC, liver and renal function tests, condition being treated) Implementation Arrange for laboratory tests before and periodically during therapy. Administer drug as indicated. Protect person from exposure to infection. Provide supportive and comfort measures to deal with adverse effects. Monitor nutritional status and intervene as needed.

Provide teaching regarding the drugs and their dosage, adverse effects, precautions and warning signs to report to care provider. Evaluation Evaluate drug effects: prevention of transplant rejection, improvement of autoimmune disease. Monitor for adverse effects: infection, flu-like symptoms, GI upset, fluid overload, neoplasm. Monitor for drug–drug interactions and drug–food interactions. Evaluate effectiveness of teaching program and of comfort and safety measures. TEACHING FOR T.B.: CYCLOSPORIN, MYCOPHENOLATE AND CORTICOSTEROIDS • You will need to take a combination of drugs to prevent your body from rejecting your new organ. These drugs include cyclosporin, mycophenolate and corticosteroids. They suppress the activity of your immune system and prevent your body from rejecting any transplanted tissue. • You should never stop taking your drugs without consulting your healthcare provider. If your prescription is low or you are unable to take the medication for any reason, notify your healthcare provider. • You should not take your cyclosporin with grapefruit juice. • Some of the following adverse effects may occur: • Nausea, vomiting: Taking the drug with food and eating small frequent meals may help. It is very important that you maintain good nutrition. A consultation with a dietician may be needed to help you if these GI problems are severe. • Diarrhoea: This may not decrease; ensure ready access to bathroom facilities. • Flu-like symptoms: Rest and a cool, peaceful environment may help; paracetamol may be ordered to help relieve discomfort. • Rash, mouth sores: Frequent skin and mouth care may ease these effects. • You will be more susceptible to infection because your body’s normal defences will be decreased. You should avoid crowded places, people with known infections and working in soil. If you notice any signs of illness or infection, notify your healthcare provider immediately. • Tell any doctor, nurse or other healthcare provider involved in your care that you are taking these drugs. • You will need to schedule periodic blood tests and perhaps biopsies while you are being treated with these drugs. • Report any of the following to your healthcare provider: unusual bleeding or bruising, fever, sore throat, mouth sores, fatigue, and any other signs of infection or injury. • Keep your medications safely out of the reach of children and pets and do not share medications with anyone else.