Patient Care and Monitoring

1. Assess the patient regarding the indication for HSCT, the type of preparative regimen, and the type of donor. Determine the nonhematologic toxicity of the preparative regimen, the expected timing of engraftment after the graft is infused, along with the need for GVHD prophylaxis.

2. Determine the supportive care needs during administration of the preparative regimen, including use of indwelling central venous catheters, blood product support, and pharmacologic management of CINV, mucositis, and pain.

3. After the graft is infused, monitor CBC with differential at least daily to evaluate engraftment. Allogeneic HSCT patients experience an initial period of pancytopenia followed by a more prolonged period ofimmunosuppression, which substantially increases the risk of bacterial, fungal, viral, and other opportunistic infections.

4. Counsel the patient regarding adherence to prophylactic antibiotic, antifungal, and antiviral regimens. Evaluate the patient for infection and adverse drug reactions to antibiotics, antifungals, and antivirals. Ensure that the patient is appropriately immunized after recovery from HSCT.

5. Counsel the patient regarding adherence to GVHD prophylaxis and treatment. Monitor and manage for adverse drug reactions.

Monitor for acute nonhematologic toxicity to the preparative regimen to approximately day +30. Specifically,

• Monitor the inside of the mouth and assess patient's the mouth pain for signs and symptoms of mucositis.

• Monitor weight and skin color daily to observe sudden weight changes suggesting sinusoidal obstruction syndrome. Obtain a total bilirubin determination at least twice weekly or more frequently if sinusoidal obstruction syndrome is suspected based upon weight change.

Monitor for signs of acute GVHD at least daily during engraftment and more often if GVHD is suspected or diagnosed. The patient and his or her caregivers should be educated regarding the signs and symptoms to self-monitor for GVHD. The signs and symptoms for acute GVHD that occur between day +0 and day +100 are rash, nausea, diarrhea, jaundice, elevated liver function tests, and elevated bilirubin.

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