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Lung and heart-lung transplantation: implications for nursing care when hospitalized outside the transplant center.

The goal of lung and heart-lung transplantation is to improve the survival and quality of life of patients with end-stage lung disease. More than 15,000 of these transplants have been reported in adults worldwide since 1982; slightly more than 1,000 transplants were performed in the United States in the year 2000 alone (Hosenpud, Bennett, Keck, Boucek, & Novick, 2001). As the techniques for single and bilateral lung transplants have been perfected and have experienced increased acceptance by insurance companies, the number of those transplants has steadily increased since 1985. At the same time, the frequency of heart-lung transplants has declined, permitting more effective allocation of donor hearts to those needing only that organ. Data from the time period 1997-2000 revealed a 1-year survival rate of 76% and 3-year survival of 58% for recipients of single or bilateral lung transplant. Statistics for heart-lung recipients are somewhat lower at 61% and 46% for 1 and 3-year survival, respectively (Hosenpud et al., 2001). Because the majority of patients listed for lung or heart-lung transplantation are expected to live less than 2 years, this reflects a significant improvement in survival for these terminally ill individuals.

With so many people receiving these transplants and progressing to hospital discharge following the surgery, significant numbers of patients have returned to their communities. Consistent with the goals of transplantation, these individuals are living at home as active participants of their families and communities. Five years after transplant, more than 80% of survivors are living with no activity limitations. Many have returned to work or school (Hosenpud et al., 2001). Someone may walk past a lung or heart-lung transplant recipient at the mall, sit next to one in a restaurant or movie theater, or attend a religious or sporting event with one, and not realize what he or she has experienced.

Many people both in and out of the health professions believe that these patients will always receive their health care at a transplant center, but often they do not. A nurse in a transplant or nontransplant hospital is increasingly likely to see these individuals admitted to his or her facility. The need for routine medical care may bring the transplant patient to a nontransplant center for treatment of community-acquired illnesses, infections, a trauma, or for life events such as childbirth. An understanding of the transplant and its implications for the patient's health will help nurses provide sound care to members of this special population.

The Transplant

Lung or heart-lung transplantation is performed for a variety of chronic end-stage lung diseases (see Table 1). The surgical procedure is performed orthotopically, meaning that the native organ is removed and the donor organ is placed in the vacated space. Surgical incisions are determined by the organ to be replaced: lateral thoracotomy for single lung transplant; transverse thoracosternotomy ("clam shell") for bilateral lung replacement; or median sternotomy for heart-lung transplant (see Figure 1). Surgical anastomoses establish continuity of circulatory (pulmonary artery and pulmonary veins) and respiratory (trachea or bronchus) pathways between the recipient's native anatomy and the donated organs. Cardiopulmonary bypass may be employed during the transplant if the heart is being replaced, or if the patient cannot be adequately oxygenated utilizing single lung ventilation and perfusion while the transplant is being performed on the contralateral organ (Shumway, 1995a, 1995b).

[FIGURE 1 OMITTED]

Following transplantation, the patient recovers in the intensive care unit (ICU). The duration of the ICU stay will vary based on the patient's preoperative illness and presurgical condition, specifics of the surgical procedure, and the response of the individual to the transplant. Goals of intensive care include optimizing oxygenation and cardiac function, returning the patient to preoperative weight (reflecting euvolemia) as quickly as possible, supporting end-organ function, and initiating and adjusting immunosuppressive therapy. Infection prevention, early mobilization (such as dangling at the bedside), and nutritional support also are aggressively pursued to optimize patient outcome (Petty, 1995). Early graft dysfunction due to reperfusion injury, undetected injury in the donor organ, and weakness of respiratory muscles may prolong ventilator time. The patient may also require additional interventions to support heart and/or lung function such as inotropic agents, a temporary or permanent pacemaker, or extracorporeal membrane oxygenation (McCarthy, 1995; Tager & Ginns, 1996).

An important focus of care after lung transplant is airway maintenance. The surgical procedure leads to denervation of the transplanted lung distal to the bronchial/tracheal anastomosis (George, Large, Boujoukos, & Turtle, 1996). Both before and after extubation, the patient needs encouragement to cough regularly to clear the airway because he or she may have little or no response to the usual cough stimuli such as saline lavage, accumulation of secretions, or the advancement of a suction catheter into the airway. Normal mucociliary action is also impaired, increasing the risk of retention of secretions and associated mucus plugging at levels distal to the anastomosis (George et al., 1996). Regular endotracheal suctioning prior to extubation is replaced after extubation with frequent incentive spirometry, coughing, and deep breathing, often in association with pummeling and postural drainage or vest vibration therapy. After the patient is hemodynamically stable, and able to breathe spontaneously and oxygenate adequately, he or she will be transferred from the ICU to a step-down or general care area.

Discharge Criteria

The patient is deemed ready for hospital discharge when able to demonstrate competence in self-care activities such as medication management, and understanding of and ability to manage the post-discharge routines (such as measuring vital signs, ADLs, and followup appointments) (see Table 2). Additionally, improving activity tolerance and ability to participate in rehabilitation promotes safety in the home environment. Meeting these discharge criteria can be challenging for a patient recovering from major surgery, and it is rarely accomplished without anticipated assistance from family members or other support systems. The average transplant recipient takes 13 medications daily (range 5-24) following lung or heart-lung transplantation (Teichman, Burker, Weiner, & Egan, 2000), a daunting task regardless of whether medication regimens were more or less complicated before surgery. Even for the most well-informed patient, coordination of medications, self-care regimens (bathing, meal preparation, etc.), symptom and health indices monitoring (vital signs, pulmonary function, cough, etc.), clinic appointments, and other prescribed activities can leave the patient dazed and exhausted (Snyder, Chlan, Finkelstein, Sabati, & Edin Stibbe, 1998). Hence, family members and others in the recipient's support network also receive information and education to permit them to assist the patient in the ongoing recovery process, particularly in the first 8 weeks following transplant.

After discharge from the hospital, the patient will return to the transplant clinic frequently (perhaps twice weekly) in the beginning. As recovery progresses, the frequency of transplant clinic visits is reduced. While staff at the transplant center generally want to continue to follow patients for transplant-related issues, the center is not intended to become the primary care provider. The patient is encouraged to return to his or her primary care team for issues of health maintenance (annual physical examination, health screening examinations, etc.) and as a main resource for routine illnesses. Regular communication between the transplant center and the primary care team permits smooth transition from the hospital environment to the home environment, provides continuity of care, and provides the primary care providers with a resource for questions they may have about the care of the patient related to transplant.

Common Complications Following Transplant

Tager and Ginns (1996) divided the complications of lung transplantation into three groups: those related to the surgical procedure (retained secretions, atelectasis, air leaks, pneumothorax, airway dehiscence); those related to the immunology of transplant (hyperacute, acute, and chronic rejection of the transplanted organ); and those related to immunosuppressive therapy (infection, malignancy, other organ dysfunction due to medication side effects). If these complications occur, their appearance generally follows a predictable time line. Within the first 4 weeks of transplant, the predominant complications reported are associated with the surgery itself, hyperacute or acute rejection, and infections of wounds or invasive lines along with bacterial pneumonia and fungal infections. The potential for developing bacterial pneumonia and fungal infections persists over the subsequent few months (a time when the patient is likely to have returned home), with the likelihood of viral infections such as cytomegalovirus (CMV) and respiratory syncitial virus rising over the time period of 4 weeks to 6 months following transplant. Chronic rejection, infection, malignancy, and organ dysfunction related to immunosuppressive medications are more likely to appear 6 months or more following transplant.

The patient is encouraged to contact the medical team if any changes in function or sense of well-being are detected to allow the health care experts to intervene as early as possible to achieve the best outcome. If the patient is still near the transplant center, evaluation and treatment can be sought there. If the patient has returned home, the primary care team can begin this process and seek consultation if needed from the transplant center staff.

Rejection. The most common causes of death and illness in the post-transplant period are rejection and infection (Hosenpud et al., 2001). Although acute organ rejection is seen with decreasing frequency after the first year following lung or heart-lung transplantation, it can occur at any time for the rest of the transplant patient's life. Further, the effects of acute rejection are both immediate and long term, in that the patient with frequent episodes of acute rejection is more likely to experience chronic rejection.

Ideal immunosuppressive therapy involves a delicate balance. Too little can result in organ rejection, while too much can compromise the patient's capacity to resist infection. Therefore, regular blood tests are performed. Evaluation of the blood level of calcineurin-inhibiting agents, which impair T-cell activation (cyclosporine [Sandimmune[R], Neoral[R], Gengraf[R]], tacrolimus [Prograf[R] FK506]), involves measuring trough levels. Blood sampling is commonly performed in the local hospital or clinic 1 hour prior to the next scheduled dose, and the blood tube is then sent to the transplant center for testing. A similar process is used to test the trough level of sirolimus (Rapamycin[R], Rapamune[R]), an inhibitor of T-cell differentiation. By contrast, monitoring of the effect of purine synthesis inhibitors, which impair lymphocyte replication and proliferation (azathioprine [Imuran[R]], mycophenolate mofetil [MMF, CellCept[R]]), is accomplished by following white blood cell (WBC) counts, targeting a goal of 3,000 to 6,000/[mm.sup.3]. Increased levels of either agent, while preventing rejection, can increase the infectious risk to the patient. However, reduced levels of the calcineurin inhibitors or sirolimus can increase the risk of rejection, as can inadequate levels of purine synthesis inhibitors (reflected in increased WBCs). Inadequate levels of any of these agents, particularly in a symptomatic patient, may be treated with increased dosage, and may be supplemented with a short course of augmented steroid therapy.

Prednisone (Deltasone[R]), a corticosteroid, is the third component of the triple therapy immunosuppression developed in the early 1980s. Corticosteroids have both immunosuppressive (including alteration of T-cell proliferation) and anti-inflammatory effects. Direct measurement of their effects is not performed. Programs generally begin with doses of 0.5 mg/kg/day and decrease that dose to 0.1 mg/kg/day over 6 to 12 months. Supplemental therapy with steroids in settings of stress or acute rejection often involves methylprednisolone 15 mg/kg intravenously daily for 3 consecutive days, then a return to the previous prednisone dose.

Acute rejection is often suspected first as a result of changes in home spirometry results. Significant changes in forced exhaled volume in 1 second (FEV1) and forced vital capacity (FVC), measures of respiratory function, will trigger a clinic appointment and further evaluation, because changes may also result from pulmonary infection or other causes. The patient's cooperation with a home spirometry program can thus aid in early detection and intervention (Snyder et al., 1998). The gold standard for diagnosing acute rejection is transbronchial biopsy. If rejection is detected (or suspected in the absence of a biopsy), it will be treated with additional steroids (prednisone or methylprednisolone) and adjustments in immunosuppression. Chronic rejection is less amenable to therapy, but in some instances symptoms may improve with steroid therapy. At a minimum, the goal of steroid therapy in chronic rejection is to stop the decline in lung function as reflected in pulmonary function tests. Additional therapeutic interventions for chronic rejection may include antithymocyte globulin, methotrexate, and photopheresis, either individually or in combination. The ultimate therapy for this devastating complication is retransplantation (Hertz, 2001).

Because rejection and infection can have a similar presentation (fever, shortness of breath, leukocytosis) and similar radiographic findings, a thorough history and physical examination are key to the process of planning therapy. Measuring vital signs, oxygen saturation, arterial blood gases, laboratory studies, cultures of blood, urine, and sputum, and chest x-ray will also help to guide the team in its course of action. If team members are still in doubt, the transplant center will often be contacted for early assistance in determining the probable diagnosis and necessary interventions (Hertz, 2001; Ochoa & Richardson, 1999).

Infection. Management of infection begins with prevention. The patient is encouraged to avoid contact with others who have an infectious disease (upper respiratory infection, shingles, childhood diseases such as chicken pox, etc.) Self-care instructions include following American Heart Association guidelines for preventing subacute bacterial endocarditis with prophylactic antibiotic administration prior to dental interventions and other invasive procedures (American Heart Association, 1997). Continuous prophylaxis with antibiotics raises the risk of the development of resistant organisms. As a result, it is avoided if at all possible.

Prophylactic antimicrobial therapy is initiated in patients with known infection at the time of transplant or in those with significant risk. Because every immunosuppressed patient is at risk for infection by Pneumocystis carinii, regular (twice weekly) doses of trimethoprim-sulfamethoxazole will be administered for the remainder of the patient's life. If the patient has an allergy to sulfa, alternative Pneumocystis therapy is prescribed. Similarly, if the donor's and/or recipient's serologic evaluation demonstrates exposure to CMV prior to surgery, many programs will prophylax the recipient twice daily with oral ganciclovir for approximately 3 months following transplant. Finally, the patient with a chronic infectious disease such as cystic fibrosis may be treated for organisms that had been growing before transplant, particularly during periods of high-dose immunosuppression. Targeted treatment of known bacteria and Aspergillus is a common strategy (Hertz, 2001).

If a new infection is diagnosed, additional targeted antimicrobial therapy is needed. The choice of antibiotic is determined by the organisms cultured or suspected and the associated pattern of resistance and susceptibility. Recurrent infections, especially viral infections such as CMV, have been associated with chronic rejection (Kruger et al., 1999). To reduce the risk of this complication, aggressive therapy to eradicate this virus is used. Fungal infections, particularly Aspergillus, are also frequently reported. Because it is not unusual for a patient to be infected with more than one organism simultaneously, consideration must be given to all potential pathogens. In addition, an immunosuppressed patient may not mount a "typical" response to infection. Vague symptoms without fever or leukocytosis must be pursued to prevent subclinical infections from becoming generalized. Antibiotics alone in the patient with chronic exposure to antibiotics (such as cystic fibrosis) may not be adequate to control infection. In such a case, the cautious reduction of immunosuppression may allow the body's own systems to assist in destroying the pathogens.

End-organ dysfunction. Endorgan dysfunction of nontransplanted organs following lung transplant is frequently the result of immunosuppressive medications. The nephrotoxic and hepatotoxic effects of calcineurin inhibitors are well described (Hertz, 2001; McCarthy, 1995). Hospital admission for a lung transplant recipient with a creatinine of 1.5 to 2.5 mg% may not be alarming unless the value reflects an upward trend. However, a patient with such laboratory values will not tolerate dehydration well. Use of additional nephrotoxic agents (such as aminoglycoside antibiotics, NSAIDS, ACE inhibitors) is undertaken with caution to avoid progressive organ impairment. Similarly, medications with potential marrow-suppressing effects (such as allopurinol for acute gout) may have a more sinister effect such as pancytopenia if given concurrently with azathioprine. This can be avoided by using an alternate medication (such as colchicine). Staff at some centers will consider changing the medication regimen of a patient with chronic gout symptoms from azathioprine to mycophenolate mofetil to permit the patient to safely receive allopurinol (Hertz, 2001).

Other systems that can be negatively affected by immunosuppression include the GI system, the central nervous system, the musculoskeletal system, the endocrine system, the skin, and the psyche (Tager & Ginns, 1996). Particular attention is paid to the developments of new "lumps and bumps" to allow early testing and diagnosis due to the risk of post-transplant lymphoproliferative disorder, a form of cancer. Detecting such effects is important to prevent their extension. Cancer rates of 4.4% to 5.8% at 1-year and 5-year followups have been reported (Hosenpud et al., 2001).

Routine Illnesses: Implications for Nursing

When a patient is admitted to the hospital with an infection, a traumatic injury, or some other disruption in the usual state of health, the nurse obtains a history, performs an examination, reviews other subjective and objective data, and plans nursing care based on those findings. The transplant patient, who has many co-morbid conditions, can present unique challenges to the nurse providing this care.

While it is anticipated that the transplant will improve the recipient's cardiopulmonary function, life does not normalize because the transplant patient has exchanged a life-threatening illness (end-stage lung or heart-lung disease) for one which is less so (lung or heart-lung transplant). Further, the nurse must remember the effect of the illness precipitating the need for transplant on body systems apart from the heart and lungs. For instance, the patient with cystic fibrosis (CF) who undergoes heart-lung or bilateral lung transplantation will still require medication to treat the gastrointestinal aspects of CF. These include malabsorption, motility difficulties, and disorders of glucose metabolism. For the single-lung transplant recipient who has emphysema due to alpha-1 antitrypsin deficiency, the hepatic aspects of alpha-1 disease may persist. In the ICU, positive pressure ventilation in a patient after single lung transplant for an air-trapping disease like emphysema may require special manipulation to prevent hyperinflation of the native diseased lung (Hertz, 2001; McCarthy, 1995).

Special Considerations

If a lung transplant recipient is admitted to the hospital with an infection, most transplant programs have abandoned the use of reverse isolation techniques unless the patient has experienced myelosuppression that results in severe compromise of the immune system. If the patient's absolute neutrophil count is abnormally low, treatment will usually include protective isolation techniques (Phipps, Monahan, Sands, Marek, & Neighbors, 2003). Good handwashing and routine general precautions will suffice to protect the patient in most other instances if these practices are consistently followed by all who come in contact with the patient. Of course, health care personnel and visitors with upper respiratory infections should not have contact with a patient who is immunosuppressed; if this is unavoidable, those individuals should mask and redouble their efforts regarding handwashing. Sterile technique when inserting and dressing intravenous lines and other tubes is also key. Accurate and timely administration of prescribed antibiotics will have the best chance of killing infectious organisms before they have a chance to spread and cause general debilitation in the patient who has undergone transplantation.

Special attention to the unique toxicities of antibiotic, antifungal, and antiviral agents will also be important to the patient whose transplanted organs are at risk and whose other organs are already under siege from routine immunotherapy. Collaboration with a doctorally prepared pharmacist or staff at the transplant center can provide insight into the implications of certain medication combinations. Because antibiotics can significantly raise or lower blood levels of immunosuppressants, consultation is critical to prevent one course of therapy from interfering with another. Astute attention to changes in end-organ function, which may result from the addition of an antimicrobial agent, is an integral part of ongoing nursing assessment.

Pulmonary toilet. Preventing or treating pulmonary infection requires diligent attention to pulmonary toilet. If the patient is intubated, suctioning the airway is important when secretions are present. A suction catheter should only be advanced to the end of the endotracheal tube while asking the patient to cough. Because denervation of distal airways eliminates the cough reflex usually stimulated by the advancing catheter, passing the suction catheter as deeply as possible has no beneficial effect. The potential for disrupting or injuring the delicate airway mucosa presents a significant risk to the patient whose risk of infection is elevated by being intubated (Petty, 1995).

In the nonintubated patient, regular coughing and deep breathing supplemented by bronchodilators, pummeling and postural drainage, and/or vest vibratory therapy should be continued as at home. Again, because the usual cues to cough do not work in the lung transplant recipient, scheduled coughing exercises are generally of benefit in preventing the buildup of secretions. The nurse can help this effort by including the coughing exercises in the plan of care and reminding the patient to practice the exercises as needed (Meyer et al., 1996).

Rejection/immunosuppression. Any disruption of the immunosuppressive regime increases the risk of acute rejection and associated organ dysfunction. Because the implications are dire, every effort must be made to maintain or restore immunosuppressive therapy as soon as possible if such a disruption occurs. The patient who presents with a 24-hour history of nausea, vomiting, and/or diarrhea is at increased risk of incomplete absorption of life-sustaining medications, and needs to have the agents administered by an intravenous route (see Tables 2 & 3) (Hertz, 2001). Conversion of oral prednisone to intravenous methylprednisolone can be made on a 0.8 mg to 1.0 mg basis. Intravenous azathioprine is given once daily at a dose that is 50% of the daily oral dose. Mycophenolate mofetil is administered on a one-to-one conversion of oral to intravenous dose, mixed only in D5W, and infused once daily over 2 to 3 hours. Cyclosporine is initiated at 40 mcg/kg/hour intravenously and titrated to achieve steady state levels equivalent to the target trough levels desired with oral dosing. Tacrolimus is initiated at 0.03 to 0.05 mg/kg/day and is titrated to achieve a steady state similar to the target trough level of the oral dose (Hertz, 2001; McEvoy, 2001).

The development of acute rejection despite such early resumption of immunosuppression will require augmentation of therapy. High-dose steroids (for example, methylprednisolone [Solu-Medrol[R]] 1 gm IV daily for 3 days) may be used to aggressively control the immune system until therapeutic levels of the other agents are achieved (Hertz, 2001; McEvoy, 2001).

Stress response. The ability of the patient's body to mount a stress response following a traumatic injury may be altered after lung or heart-lung transplant. Chronic steroid therapy, which is part of the immunosuppressive regimen, will impair the ability of the adrenal cortex to meet the challenge of such an insult to the body. Replacement "stress dose" steroids are an important part of helping the patient to meet the challenges facing all organ systems as a result of the injuries. Whether undergoing surgery, having nonsurgical therapy for injuries, or simply having experienced a traumatic event, the patient often will require physiologic support through the episode. Nursing efforts to minimize the impact of stress will include grouping care tasks, promoting rest, encouraging slowly progressive activity, promoting nutrition, and meeting psychological and emotional needs of the patient (Karch, 2003).

Skin. Skin management becomes very important for the patient after transplant because of the increased risk of infection and because steroids can significantly increase the propensity of skin to breakdown. Close and regular inspection of the skin for signs of pressure injury, tears, or other disruption is crucial to effectively care for these patients. Using the Braden system to assess risk of skin impairment and providing early intervention will be invaluable. If skin breakdown occurs, scrupulous attention to use of prescribed therapies, pressure relief, and close monitoring to promote healing will reduce the risk of extension of the wound or the infection.

End-organ function. Lung and heart-lung transplant recipients are often at risk for renal dysfunction. Close monitoring of intake and output and daily weight will aid in evaluating the patient's hydration status and permit early intervention to minimize the endorgan complications of fluid volume excess or inadequacy. Other well-described extrapulmonary medical problems of organ recipients, generally attributed to medication side effects, include hypertension (calcineurin inhibitors), electrolyte abnormalities (calcineurin inhibitors), gastroparesis (pain medications, other agents), peptic ulcer disease (steroids), cholecystitis, neurologic problems (cyclosporine), hyperlipidemia (cyclosporine, steroids, sirolimus), and osteoporosis (steroids) (Hertz, 2001). While each of these problems can be addressed in the local hospital, collaboration with the transplant center will enhance the coordinated and effective management the patient is seeking.

Routine illnesses can result indirectly in significant, unanticipated negative consequences for the patient due to the interaction of new medications and the patient's transplant drug regimen. The nurse will understand the indications for new medications prescribed, but must also identify the potential interaction between new medications and current medications related to the transplant. For example, the patient receiving calcineurin inhibitors (tacrolimus and cyclosporine) or on chronic steroid therapy often develops significant hypertension requiring medical intervention. Such hypertension can be quite refractory to drug management, requiring increased doses of the standard agents (diuretics, ACE inhibitors, beta blockers, calcium channel blockers). At the same time, these agents can exacerbate other problems. For example, diuretics and ACE inhibitors can lead to worsening renal dysfunction. They can also directly affect cyclosporine and tacrolimus levels; for example, nifedipine increases blood level of cyclosporine without a dose change (Hertz, 2001). Managing this problem is anything but usual in the lung transplant patient, because persistent attention to the function of all organ systems is required. The collaborative effort of the physician, nurse, pharmacist, social worker, and staff of the transplant center will assure that the patient receives effective therapy and achieves the best outcomes (see Figure 2).

Summary

Lung or heart-lung transplantation is a procedure frequently performed to treat end-stage lung disease. Survival statistics reveal the effectiveness of this therapy, and increasing numbers of patients are in the community. When they experience disruptions in their health, these patients are as likely to be admitted to nontransplant as well as to transplant facilities.

Lung transplant recipients have successfully undergone surgical procedures, such as cholecystectomy, other intra-abdominal surgical procedures, and sinus surgery. They have given birth to viable and healthy babies. In general, they have returned to a "normal" life complete with all of its major events. Their success is in part dependent on the knowledgeable and coordinated care provided by the nurses, physicians, and other members of the health care team. The transplant center staff provides support and guidance in managing the care for these special patients.

Figure 2. Patient Guidelines Following Lung Transplant

"What Should I Do When I Get Home from the Hospital?"

[check] Re-establish your home routine for:

* Taking and recording vital signs and other tests requested by the transplant center/primary care team.

* Taking your medications--use a "double-check" system with a family member/support person to prevent forgetting your medications.

* Periods of activity and rest; increase your activity level slowly as your condition permits.

[check] Resume your home spirometry program.

[check] Set up followup appointments with you primary care team and transplant team.

[check] Monitor your body's signals to you, telling you how you are progressing. You will know how you are recovering better than anyone.

[check] Report chancres to your medical team. REMEMBER: Your job is to detect changes, the medical team's job is to determine the meaning/importance of those changes!

"When Should I Call the Doctor/Transplant Center after Being Discharged from the Hospital?"

[check] Fever (temperature greater than 100.5 F orally), shaking chills, night sweats.

[check] Shortness of breath, changes in breathing pattern, increased sputum production, changes in sputum color.

[check] Change in activities of daily living, change in activity tolerance.

[check] Change in vital signs (blood pressure, heart rate, oxygen saturation, pulmonary function tests).

[check] Any other changes in the way you feel, even if you don't know what they mean.

"Why Does the Transplant Center Need to Know about New Prescriptions I Get from My Primary Team?"

[check] They will add the medication to the list of current medications they have recorded for you.

[check] They may need to adjust your anti-rejection medications or have a blood level drawn sooner than previously planned.
Table 1.
Adult Transplant Indications (1982-1999)

Transplant Type   Indications

Single Lung       COPD (47.0%)
Transplantation   Idiopathic pulmonary fibrosis (21.0%)
                  Miscellaneous (11.0%)
                  Alpha-1 antitrypsin deficiency (11.0%)
                  Primary pulmonary hypertension (4.0%)
                  Cystic fibrosis (3.0%)
                  Retransplant (3.0%)

Bilateral or      Cystic fibrosis (33.3%)
Double Lung       COPD (20.1%)
Transplantation   Miscellaneous (17.7%)
                  Alpha-1 antitrypsin deficiency (9.8%)
                  Primary pulmonary hypertension (9.0%)
                  Idiopathic pulmonary fibrosis (7.8%)
                  Retransplant (2.2%)

Heart-Lung        Congenital disorders (32.4%)
Transplantation   Primary pulmonary hypertension (25.4%)
                  Cystic fibrosis (16.3%)
                  Miscellaneous (12.8%)
                  COPD (4.4%)
                  Alpha-1 antitrypsin deficiency (3.1%)
                  Idiopathic pulmonary fibrosis (2.8%)
                  Retransplant (2.6%)

Adapted from Hosenpud et al. (2001)


Table 2. Discharge Criteria: Patient/Family Goals

1. Performs activities of daily living (ADLs) while appropriately limiting activity based on postoperative recovery restrictions.

2. Self-administers all medications accurately and timely; demonstrates ability to identify major indications and side effects of each of the principal post-transplant medications; demonstrates ability to accurately document changes in medication dosage made by transplant team.

3. Accurately identifies how and when to call primary care physician and/or transplant team for changes in condition.

4. Family members express understanding, involvement, and participation in the patient's ongoing care and recovery.

Adapted from Petty (1995).
Table 3.
Frequently Asked Questions About Caring for Transplant Recipients

Does the patient         No, unless severe immunocompromise exists
require protective       (absolute neutrophil count < 500/[mm.sup.3]).
isolation?               Use good handwashing technique and sterile
                         technique for dressing changes, and do not
                         permit caregivers or family members with upper
                         respiratory infections to have contact with
                         the patient unless masked.

What should I do if      If the patient is unable to take oral
the patient is           immunosuppressive agents, request conversion
unable to take           to IV formulations:
medications orally?      * 1 mg oral prednisone = 1 mg IV
                           methylprednisolone
                         * 1.0 mg oral azathioprine = 0.5 mg IV
                           azathioprine
                         * 1 mg oral mycophenolate mofetil = 1 mg IV
                           mycophenolate mofetil, mix IV form only in
                           D5W, infuse over 2-3 hours.
                         * Oral cyclosporine/neoral = begin infusion at
                           40 mcg/kg/hr IV continuously, titrating to
                           achieve steady state equivalent to target
                           trough value
                         * Oral tacrolimus = begin continuous infusion
                           at 0.03-0.05 mg/kg/day, titrating to achieve
                           steady state equivalent to target trough
                           value
                         * 1 mg oral rapamycin (tablet)= 1 mg oral
                           rapamycin (solution) (no IV form available)
                         (McEvoy, 2001)

What special nursing     Concerns can include:
concerns are             * Infection
associated with lung     * Pulmonary toilet
and heart-lung           * Rejection
transplant recipients?   * Stress response
                         * Skin care
                         * End-organ function
                         * Medication interactions

How will I know if a     Refer to drug manuals, pharmacists, and
medication can have a    physicians. If uncertain, contact the
negative impact          transplant center for further information.
specifically on a
transplant patient?


References

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Hertz, M.I. (Ed.) (2001). Manual of lung transplant medical care (2nd ed.). Minneapolis, MN: Fairview Press.

Hosenpud, J.D., Bennett, L.E., Keck, B.M., Boucek, M.M., & Novick, R.J. (2001). The registry of the International Society for Heart and Lung Transplantation: Eighteenth official report--2001. Journal of Heart and Lung Transplantation, 20(8), 805-823.

Karch, A.M. (2003). 2003 Lippincott's nursing drug guide. Philadelphia: Lippincott, Williams & Wilkins.

Kruger, R.M., Shannon, W.D., Arens, M.Q., Lynch, J.P., Storch, G.A., & Trulock, E.P. (1999). The impact of ganciclovir resistant cytomegalovirus infection after lung transplantation. Transplantation, 68(9), 1272-1279.

McCarthy, P.M. (1995). Immediate postoperative care after thoracic organ transplantation. In S.J. Shumway, & N.E. Shumway (Eds.), Thoracic transplantation. Philadelphia: Blackwell Science.

McEvoy, G.K. (Ed.). (2001). American hospital formulary service (AFHS) drug information 2001. Bethesda, MD: American Society of Health-System Pharmacists, Inc.

Meyer, S.B., Bass, M., Ash, R., Duffy, S., Gazarian, G.G., Parello, A.P. et al. (1996). Postoperative care of the lung transplant patient. Critical Care Nursing Clinics of North America, 8, 239-252.

Ochoa, L., & Richardson, G. (1999). The current status of lung transplantation: A nursing perspective. AACN Clinical Issues, 10(2), 229-239.

Petty, M. (1995). Nursing care considerations in thoracic transplantation. In S.J. Shumway & N.E. Shumway (Eds.), Thoracic transplantation. Philadelphia: Blackwell Science.

Phipps, W.J., Monahan, F.D., Sands, J.K., Marek, J.F., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis, MO: Mosby.

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Michael Petty, MS, RN, CCNS, CNS, is a Cardiothoracic Clinical Nurse Specialist, Fairview-University Medical Center, Minneapolis, MN.
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Author:Petty, Michael
Publication:MedSurg Nursing
Date:Aug 1, 2003
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