造血幹細胞移植後嚴重植體拉宿主疾病之護理經驗

The Nursing Experience of a Patient with Severe Graft Versus Host Disease after Stem Cell Transplantation

個案為一罹患白血病的中年婦女在其接受減毒性調適療程及非親屬間週邊幹細胞移植120 天後，出現腸胃道及皮膚第三度排斥；在排斥控制療良好後，卻因免疫抑制導致巨細胞病毒（Cytomegalovirus, CMV）濃度上升；在治療CMV 時，又因藥物副作用導致骨髓抑制，全血球低下。由此可知，在移植後的整體治療上，需要微妙的調整各種藥物劑量以控制其交互作用，並在預防感染及抗排斥中間取得一個平衡點，就彷彿走鋼索一般，一不留神走偏至哪邊，都會有生命危險。筆者發現個案極度專注於身體症狀及檢驗值，而這牽動其每日的情緒起伏以及行為。護理師除了需提供適切的移植後初期護理照護，對於瞭解移植後病人的因應行為與持續護理也非常重要。文中筆者運用Watson 人性關懷理論並連續性接觸個案以及幹細胞移植之專業知識與護理技能，早期評估發現問題，並做有效處理。透過護理介入措施與個案解釋植體對抗宿主疾病 （graft-versus-host-disease, GVHD）之進展及協助個案適當監測身體變化，並且教導皮膚GVHD 的照顧，使個案接受其身體心像改變，進而能調整、接受並適應移植後的身心變化。

A 53-year-old woman has developed grade III graft-versus-host-disease (GVHD) of skin and gastrointestinal tract at 120 days after receiving an HLA- partially matched unrelated donor peripheral blood stem cell transplantation for her acute lymphoblastic leukemia through a reduced-intensity conditioning protocol. Although the GVHD can be gradually controlled by the combination of multiple immunosuppressing agents, her immune function was compromised that resulted in subsequent flare-up of cytomegalovirus. Unfortunately, the effective anti-viral agents had adverse effect of bone marrow suppression and pancytopenia. Thus, to keep an appropriate balance by adjusting various medications between control of GVHD and prevention of infection is important for patient. It's just like walking on the ropes - carelessly leaning to either side would put the patient in great danger. The author found that the patient's daily emotion and behavior was tremendously influenced by the awareness of her symptomatology and a serial of laboratory data. In addition to providing the proper primary nursing care after transplantation, we should understand the patient's behavior and provide continuous care. In this case experience, continually caring of this patient and understanding related knowledge about stem cell transplantation provides more effective management from the very beginning of disease complications. The nursing interventions in this case includes using Watson's human caring theory , explaining manifestations of GVHD progression, helping patient to properly monitor any change in her body, and teaching patient how to take care of skin GVHD by herself. These interventions enable the patient to accept her changing body image gradually and finally to achieve a proper accommodation of physical and mental change after transplantation.