Nursing Considerations for Patients Receiving Immune Suppressants 免疫抑制剂患者的护理考虑
Assessment: History and Examination 评估：病史和检查
• Assess for contraindications and cautions: any known allergies to any of these drugs or their components to prevent hypersensitivity reactions; current status related to pregnancy or lactation because of the potential risk to the fetus or baby; history of renal or hepatic impairment that might interfere with drug metabolism and excretion; and history of neoplasm, which could be exacerbated with the use of these drugs.
评估有无禁忌症和注意事项：对这些药物或其成份的任何已知过敏，防止过敏反应；与妊娠或哺乳相关的现病史，因为对胎儿或婴儿有潜在风险；肾或肝损害史，可能影响药物的代谢和排泄；肿瘤史，使用这些药物可能加重病情。
• Perform a physical assessment to determine baseline status before beginning therapy and for any potential adverse effects: Inspect the skin to detect the presence of any lesions; obtain weight to monitor for fluid retention; monitor temperature to monitor for potential infection; monitor pulse and blood pressure to assess the cardiac effects of these drugs; assess level of orientation and reflexes to monitor for any CNS changes associated with drug use.
进行体格评估，确立治疗前及为潜在不良效应提供基线资料：检查皮肤，检出任何病损；获取体重，监测有无液体潴留；监测体温，监测有无潜在感染；监测脉搏和血压，评估药物的心脏效应；评估定向力和反射水平，监测有无药物使用相关的CNS变化。
• Obtain a baseline ECG to evaluate cardiac function.
获取基线ECG，评价心脏功能。
• Assess the patient’s renal and liver function, including renal and liver function tests, to determine the appropriateness of therapy and determine the need for possible dose adjustment and toxic drug effects.
评估患者肾、肝功能，包括进行肾、肝功能试验，确定疗法的适用性，确定是否需要调整剂量，确定药物毒性效应。
• Monitor the results of laboratory tests such as CBC to identify changes in bone marrow function.
监测实验室检查结果，如CBC，以确定骨髓功能变化。
Nursing Diagnoses 护理诊断
Nursing diagnoses related to drug therapy might include:
药物相关的护理诊断可能包括：
• Acute Pain related to CNS, GI, and flu-like effects
急性疼痛，与CNS、GI和流感样效应有关
• Risk for Infection related to immune suppression
感染风险，与免疫抑制有关
• Imbalanced Nutrition: Less Than Body Requirements, related to nausea and vomiting
营养失调：低于身体需要，与恶心和呕吐相关
• Deficient Knowledge regarding drug therapy
知识缺乏，与药物疗法相关
Implementation With Rationale 实施及说明
• Arrange for laboratory tests before and periodically during therapy, including CBC, differential, and liver and renal function tests, to monitor for drug effects and adverse effects.
治疗前及治疗期间定期安排实验室试验，包括CBC、鉴别分析、肝肾功能试验，以确定有无药物效应和不良效应
• Administer the drug as indicated; instruct the patient and a significant other if injections are required to ensure proper administration of the drug.
按处方给药；需要注射时指导患者和亲属，确保正确给药。
• Protect the patient from exposure to infections and maintain strict aseptic technique for any invasive procedures to prevent infections during immunosuppression.
保护患者，避免感染暴露，任何侵入性操作招待严格的无菌操作，预防免疫抑制期间出现感染
• Arrange for supportive care and comfort measures for flulike symptoms (rest, environmental control, acetaminophen) to decrease patient discomfort and increase therapeutic compliance.
为流感样症状安排支持性护理和舒适措施（休息、环境控制、醋氨酚），减轻患者不适，增强治疗依从性。
• Monitor nutritional status during therapy; provide small, frequent meals, mouth care, and nutritional consultation as necessary to ensure adequate nutrition.
监测治疗期间的营养状况；少量多餐，进行口腔护理，必要时提供营养咨询，确保营养充分。
• Instruct female patients in the use of barrier contraceptives to avoid pregnancy during therapy because of the risk of adverse effects to the fetus.
指导女性患者如何进行屏障避孕，避免治疗期间怀孕，鉴于对胎儿的不良效应风险。
• Offer support and encouragement to help the patient deal with the diagnosis and the drug regimen.
提供支持与鼓励，帮助患者处理诊断和药物治疗方案问题。
• Provide thorough patient teaching, including measures to avoid adverse effects, warning signs of problems, and proper administration, to increase knowledge about drug therapy and to increase compliance with the drug regimen.
提供彻底的患者宣教，包括制订措施避免不良不、问题警示标志及正确给药，以增加药物治疗知识，增强对药物疗法的依从性。
• Offer support and encouragement to help the patient deal with the diagnosis and the drug regimen.
提供支持和鼓励，
Evaluation 评价
• Monitor patient response to the drug (prevention of transplant rejection; improvement in autoimmune disease or cancer; prevention of RSV disease; improvement in signs and symptoms of Crohn disease or rheumatoid arthritis).
监测患者对药物的反应（移植排斥预防；自体免疫疾病或癌症的改善，RSV病预防）
• Monitor for adverse effects (flu-like symptoms, GI upset, increased infections, neoplasms, fluid overload).
监测有无不良效应（流感样症状、GI不适、感染增加、肿瘤、液体过载）
• Evaluate the effectiveness of the teaching plan (patient can name drug, dosage, adverse effects to watch for, specific measures to avoid adverse effects, proper administration technique).
评价宣教效果（患者可以说出药名、需要注意的不良效应、避免不良效应的具体措施、正确的给药技术）
• Monitor the effectiveness of comfort measures and compliance to the regimen (see Critical Thinking Scenario).
监测舒适措施效果和对治疗的依从性（见评判性思维场景）
★Vocabulary for Today ★
常用单克隆抗体2-2
Mylotarg – n. 麦罗塔
ibritumomab – n. 替伊莫单抗
Zevalin – n. 泽娃灵
infliximab – n. 英夫利昔单抗
Remicade – n. 类克
natalizumab – n. 那他珠单抗
Tysabri – n. 塔沙布里
omalizumab – n. 奥马佐单抗
Xolair – n. 索雷尔
palivizumab – n. 帕利珠单抗
Synagis – n. 西那吉斯
pegaptanib – n. 培加尼布
Macugen – n. 马库根
rituximab – n. 利妥昔单抗
Rituxan – n. 瑞图宣
tocilizumab – n. 托珠单抗
Actemra – n. 雅美罗
tositumomab – n.托西莫单抗
iodine-131 tositumomab -- 131碘托西莫单抗
Bexxar – n. 百克沙
trastuzumab – n. 曲妥珠单抗
Herceptin – n. 赫赛汀
ustekinumab – n. 乌司妈单抗
Stelara – n. 喜达诺
Muromonab-CD3 – 莫罗单抗-CD3
★Video ★
Monoclonal Antibodies – Brief
★Test ★
1. The client diagnosed with chronic kidney disease (CKD) is admitted to the medical floor for pneumonia. The admission orders include Zithromax, cyclosporine, and Mylanta. Which question should the nurse ask the client?
A. “Are you allergic to iodine or any type of shellfish?”
B. “When is the last time you had your dialysis treatment?”
C. “Have you had any type of organ transplant?”
D. “Why don’t you take aluminum hydroxide instead of Mylanta?”
2. The nurse is preparing to administer the morning medications to the client who is 1-day postoperative total knee replacement. Which medication should the nurse question administering? A. Ceftriaxone B. Enoxaparin C. Cyclosporine D. Morphine
1. C. “Have you had any type of organ transplant?” Rationale: Cyclosporine would not be an expected medication for a client diagnosed with pneumonia or CKD, unless the client has had a kidney transplant; therefore, asking this question is appropriate. 2. C. Cyclosporine Rationale: Cyclosporine (Neoral), an immunosuppressant, is not an expected medication to be prescribed for a client recovering from with total knee replacement. The nurse should determine why the client is receiving this medication. The client taking cyclosporine has had some type of organ transplant. This is important information to include in discussions with others caring for the client.
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