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(excerpted from Thomas’ Hematopoietic Stem Cell Transplantation, 5th Edition) The first interface many patients have with an HCT transplant program occurs at the time they come for a second opinion. Often patients make a consultation appointment to compare a particular program with other centers they are considering. These patients meet with a transplant physician to review their options, a financial counselor, and a nurse. The nurse’s role is to assist the patient with this decision by explaining the logistics of the program, including the usual length of stay on the inpatient unit and how much of the transplant process will be managed on an outpatient basis. Many patients are interested in the nursing services at the program they are considering and ask questions about the nurse-to-patient ratio. The responsibilities of the patient’s caregiver are reviewed as well. At that time, many families are concerned with the logistics of relocating and incorporating this intense therapy into their lives. These patients present with a myriad of questions, and the nurse must be versatile in meeting the patients’ and families’ informational needs. Nurses often are also responsible for giving information regarding the transplant program to physicians and nurses from the referring center as well as to third-party payers. Understanding of the overall transplant process and time commitment Current symptoms from previous therapies or disease Current coping ability Current pain Current blood product requirements Sedation preference for procedures Length of time for work-up, mobilization, and transplant process Role of caregiver Care coordination Confirm family/Friend plan for caregiving. Contact referring physician’s office to obtain report Confirm financial clearance Confirm housing plan Maintain working knowledge of proposed transplant plan for patient Once a patient has met initial screening and has decided to undergo HCT at a specific center, the nurse’s primary responsibility becomes education. The patient must understand the specifics of the rigorous evaluation. The coordination and timing of care during this phase is especially critical if the patient has an unrelated donor. The completion of work-up and the initiation of conditioning must start on an exact date to allow HSC infusion on the planned date of HSC procurement. The generosity of the volunteer donors must be respected and accommodated. Patient’s current fears and concerns Barriers to learning Current pain Knowledge of disease status Knowledge of transplant process Knowledge of patient’s rights and responsibilities when participating in medical research Usual coping strategies Level of fatigue and usual sleep patterns Patient’s experience in other health-care environments Identified caregiver(s)’ commitment Identified caregiver(s)’ barriers to learning Allergies Current medications and knowledge of purpose Adherance in taking medications Culture for presence of antibiotic resistant organisms Current central venous access History of central venous access Logistics for working with home infusion companies and administration of home infusions. Clinic logistics, including how to access care after hours Importance of having a caregiver during various phases of the transplant process Purpose of procedures, laboratory tests, and scans required for work-up Overall transplant process Usual complications of transplant Central venous catheter preoperative teaching Assess ability to adhere to work-up schedule Confirm financial clearance for transplant Social work assessment Nutrition assessment Maintain working knowledge of proposed transplant plan for patient Ensure all work-up studies are obtained in a timely manner Preconditioning The nurse plays an important role in the informed consent process, supporting the medical staff’s explanations and plans to ensure, as much as possible, that the patient is making an informed decision regarding HCT. Donor preparation Donors have been called the “forgotten patients” of transplant. The HCT recipient, appropriately, is the center of focus for the transplant team. However, donors also have concerns about their own health and the procedures they will undergo. It is ideal for donors to have a primary nurse with whom they can establish a relationship and who can prepare them for the hematopoietic cell collection and monitor them throughout the procedure. The Foundation for the Accreditation of Cellular Therapy (FACT) has also determined that the donor must be cared for by a different physician than the transplant recipient.
After your transplant, your immune system is weak and you are at risk for infection. Even though your white blood cell count might be “normal,” your immune system is still recovering. Therefore, infections might still occur. Causes of infection The usual causes of infection after a bone marrow transplant include: *These are more common after allogeneic bone marrow transplants than autologous BMTs, particularly in patients with graft-versus-host-disease (GvHD). Detecting infectionOne of the easiest and most important ways to detect signs of infection is to take your temperature. You should take and record your temperature twice a day. Preventing infection
Avoiding environmental exposuresPay close attention to hygiene This is necessary to help prevent infection. You may shower or bathe normally, as long as you don’t submerge your central venous catheter under water. Daily cleansing with soap and water is the first line of defense against bacteria on the skin. To help minimize infection and gum bleeding, daily oral (mouth) care is necessary. You may use a soft, nylon-bristled toothbrush or sponge toothette to care for your teeth and gums. Brush your teeth and gums thoroughly with fluoride toothpaste after each meal. Use a mouth wash or rinse as recommended by your healthcare provider. Prevent infections transmitted by direct contact Thorough hand washing is crucial, especially during the first 6 months after your BMT or while taking immunosuppressive medicines. Wash your hands with antimicrobial (antibacterial) soap and warm water. The use of hygienic hand rubs (hand sanitizer) is recommended when you are outside your home if soap and warm water are not available. (Keep in mind that these hand sanitizers do not prevent transmission of the bacteria responsible for causing C diff. colitis.) Handwashing is necessary:
Remember to wash your hands even if you wear gloves. Prevent infections transmitted by direct contact and respiratory transmission Avoid gardening, mulching, raking, mowing, farming, or direct contact with soil and plants. Direct contact with soil and plants increases your exposure to potential pathogens (substances that can cause disease) including aspergillus and cryptococcus. These pathogens can cause serious fungal infections. If you must do any of these activities (for example, you are a farmer), wear a mask and gloves. Avoid having anything in your yard that collects water, such as birdbaths or empty buckets. Standing water attracts mosquitoes that can transmit West Nile Virus. This does not mean you should avoid the outdoors. Walking, biking and many other outdoor activities are not only enjoyable but will promote good health. Prevent respiratory infections
Prevent pet-transmitted infections It is not necessary to part with your pets. However, it is important to minimize direct contact with animals, especially animals that are ill. Please delegate the care of your pets to other family members or friends. Avoid contact with reptiles, ducklings, or chicks to prevent infection with salmonella. If you have a cat, do not place the litter box in kitchens, dining rooms, or other areas where food preparation and eating occur. In addition, have someone else handle the daily litter box cleaning during the first 6 months after transplant and when you are taking immunosuppressive medicines to reduce your chance of getting toxoplasmosis. Please keep your cats inside and do not adopt or handle stray cats. If you have a dog, do not handle or clean up bowel movements. If hunting, do not gut animals and avoid prolonged contact with earth matter (for example, wild turkey hunting requires laying on earth surrounded by vegetative matter for cover). If fishing, avoid cleaning the fish. Small children If you have small children and are unable to avoid changing soiled diapers, you must wear gloves and a mask. After removing the changing the diaper and removing the gloves, wash your hands with soap and water. When possible have another person change diapers. Water safety After your transplant, avoid walking, wading, swimming, or playing in recreational water such as ponds, swimming pools, lakes, whirlpools, and hot tubs. Avoid drinking well water from private wells or from public wells in small communities because tests for microbial contamination are performed too infrequently. Drinking well water from municipal wells serving highly populated areas is thought to be safe because the water is tested more than two times per day for bacterial contamination. If you drink tap water, routinely monitor the mass media (radio, television, and newspapers) in your area to immediately implement any boil-water advisory. A boil-water advisory means that all tap water should be boiled for at least one minute before drinking. You may drink bottled water if it has been processed to remove cryptosporidium by one of three processes: reverse osmosis, distillation, or 1-µm particulate absolute filtration. You can contact the bottler directly to confirm that specific bottled water has undergone one of these processes. Travel safety Please do not plan to travel to developing countries without first talking to your transplant doctor. Certain countries can pose significant risks for exposure to substances, such as viruses or microorganisms, that can cause disease or infection. Vaccinations It is beneficial for family members and household contacts to be vaccinated to limit your exposure to vaccine-preventable diseases (such as tetanus, polio, measles, mumps, rubella, influenza, and pneumococcal.) Discuss influenza vaccines and all vaccines with your BMT team. Children in the household of an immunocompromised patient should receive the MMR (measles, mumps, and rubella) vaccine. Although MMR is a live vaccine, household transmission does not occur. Varicella (chickenpox) vaccine is also a live vaccine. The American Academy of Pediatrics recommends that the child in the household receive the vaccine. Varicella (chickenpox) vaccine poses a very small risk of household transmission, usually only if the vaccinated child develops a rash. If the vaccinated child develops a rash, the transplant patient might be placed on acyclovir if he or she is not already taking it. It would be much riskier for the transplant patient if the child got the actual chickenpox virus. When should I call my doctor?Watch for early signs of infection. It is very important to notify the Bone & Marrow Transplant Team or your local doctor if any of these signs or symptoms of infection occur:
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Infection control teaching for a client who is scheduled for an allogeneic stem cell transplant
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