Adult Health 2 - Transplant, Altered Immune, & Operative Complications Week 12

Pancreatitis

Spillage of pancreatic enzymes into surrounding pancreatic tissue that causes autodigestion and severe pain

Pancreatitis s/s

Degree of inflammation ranges from mild edema to severe hemorrhagic necrosis

Pancreatitis Labs

Labs helps ID severity

Serum amylase will be high

Pancreatitis Complications: Pulmonary

pleural effusion

atelectasis

pneumonia

ARDS

d/t exudate containing pancreatic enzymes

Pancreatitis Complications: Cardiovascular

Thrombi

DIC

d/t prothrombin and plasminogen activation by trypsin

Pancreatitis Complications: Hypocalcemia

Tetany is sign of severe disease

Hypocalcemia s/s

numbness/tingling

muscle cramping

dysrhythmias

Hypercalcemia s/s

Coma

dysrhythmias

renal calculi

Nursing role Pre-Op

*Pre-Op teaching

Ensure lab tests are completed

On-call med admin

Safety*

Baseline VS, H2T

Pain Management

Op site marked

Jewelry, makeup, nail polish removed

Ensure consents are signed and charted

Start IV fluids

Reason for NPO Pre-Op

Minimize risk for aspiration

Decrease risk of pos-op N/V

Meds to stop prior to surgery

Anticoagulants

GLP1

BP meds NC

Okay to take even with surgery

Time Out

Verify the person, site and procedure

Always check hx, consent, implants, px ID/wristband, studies

Mark the procedure site

Time Out: Correct patient, correct procedure, correct site and side, agreement that we are set to go

Minimal sedation responsiveness

Normal response to verbal stimuli

Minimal sedation Airway

Unaffected

Minimal sedation spontaneous ventilation

Unaffected

Minimal sedation cardiovascular function

Unaffected

Moderate sedation/analgesia responsiveness

Purposeful response to verbal or tactile stimuli

Moderate sedation/analgesia airway

no intervention required

Moderate sedation/analgesia spontaneous ventilation

adequate

Moderate sedation/analgesia cardiovascular function

usually maintained

Deep sedation/analgesia responsiveness

Purposeful response following repeated or painful stimulation

Deep sedation/analgesia airway

intervention may be required

Deep sedation/analgesia spontaneous ventilation

maybe inadequate

Deep sedation/analgesia cardiovascular function

usually maintained

General Anesthesia responsiveness

no response even with painful stimuli

General Anesthesia airway

intervention often required

General Anesthesia spontaneous ventilation

frequently inadequate

General Anesthesia cardiovascular function

may be impaired

Anesthesia

Induction agents to promote relaxation and induce sleep

PRN doses administered throughout surgery

inhalation agents

IV neuromuscular blockers

Scrub Nurse/Tech

Manages sterile items entering and leaving the surgical field

PACU Nurse Priorities

ABC assessment & monitoring

Resp management (O2, positioning, hydration, early mobilization)

Neuro assessment

Pain management (nonverbal cues)

Shivering NC

Reaction to:

- trauma

- anesthesia

- pain

- hypothermia

Abdominal Aortic Aneurysms (AAA)

Surgical nursing emergency

Permanent

AAA s/s

Often asymptomatic

May have abdominal and/or back pain

AAA Tx

If <5.4cm: monitor, RF modification

If >5.5cm: open aneurysm repair (OAR)

AAA Tx NC

OAR involves clamping the aorta

Can't clamp for longer than 45 min

Need to do frequent cardiovascular assessments

Ruptured AAA s/s

Hypovolemic shock

Tachycardia

Hypotension

Pale & clammy skin

Decreased urine output

Altered LOC

Abdominal pain

Dissecting Aortic Aneurysm

Tear in vessel wall, causing blood to pool in tear, and will eventually rupture

Life threatening emergency

Dissecting Aortic Aneurysm s/s

Abrupt start

Sudden severe sharp pain

Tearing, stabbing, or ripping pain

SOB

hypotn

Liver Resection

Up to 1/2 of the liver can be removed

Liver Resection Complication

Hemorrhage

Liver is very vascular, so there are many potential bleeding complications

Liver Resection Assessments

Liver Failure (labs)

Fevers/infections

Bile duct leakage

Pleural effusion

Clots

Complications of anesthesia

Ruptured spleen

Med emergency from forceful blunt trauma to abdomen

Ruptured spleen s/s

Pain in upper left abdomen and left shoulder

Confusion

Restlessness

Agitation

Dizziness

Poor perfusion

Ruptured Spleen Tx

Splenectomy STAT

Bariatric surgery complications

Anesthesia stores in adipose: risk for resedation

Dehiscence

Delayed healing & Wound infections

Cardiopulmonary complications from obesity

Respiratory complications from obesity

Thrombus formation

Leaks and fistulas

Electrolyte imbalances

ALS

Progressive

Loss of motor neurons

ALS Priority

Airway

GBS

Rapid demyelination

GBS priority

Airway

Muscular Dystrophy

Progressive wasting of skeletal muscle

Muscular Dystrophy Priority

Airway

Rapid Sequence Intubation

Sedation (Induction) First

Paralysis (Neuromuscular Blockers) Next

Intubate Last

Induction Agents

Etomidate

Propofol

Midazolam

Ketamine

Neuromuscular Blockers

Succinylcholine

Rocuronium (Zemuron)

Vecuronium (Norcuron)

Artificial Passive Acquired Immunity

Gamma globulin injection that provides immediate immunity (monoclonal antibodies)

May last week or months

Natural Passive Acquired Immunity

Maternal immunoglobulins to the baby

Temporary

Natural active acquired immunity

Contact with antigen through infection

Artificial active acquired immunity

Immunization and boosters

Spleen removal NC

Need to have strict adherance to vaccine regimen

Immunotherapy

Stimulates IgG release which doesn't cause histamine release

By keeping IgG high, IgE remains low and patient won't have histamine response

Immunotherapy NC

Hugh risk of severe anaphylactic reaction

Type I Hypersensitivity

IgE mediated response

ex: Allergic and anaphylactic responses

Type II Hypersensitivity

Antigen to IgG/IgM binding causes cellular lysis or phagocytosis occurs

ex: Hemolytic transfusion reactions

Type III Hypersensitivity

Antigens bound to IgM and IgG are too small, thus deposited into tissue and cause complement activation and tissue damage

ex: autoimmune, lupus, acute glomerulonephritis, RA

Type IV Hypersensitivity

Delayed Hypersensitivity reactions

Sensitized T lymphocytes release cytokines that attract macrophages and cause tissue damage

Ex: transplant rejections, contact dermatitis

Angioedema Priority

Airway

Common hospital supply that can cause an anaphylatic reaction

Latex

Use latex free everything for patient's with allergy

Over 2,000 hospital supplies contain latex

Irreversible Coma - Criteria for Death

Unreceptivity and unresponsitivity

No movement or breathing

No reflexes

Confirmatory data

What does a transplant patient need to be on for life?

Immunosuppressants

Positive Crossmatch

recipient has cytotoxic antibodies to the donor

This organ would cause a hyperacute rejection

Transplant is contraindicated

Negative crossmatch

safe to do transplant

No antibodies against donor is present

Tissue Typing

HLA typing

Panel of Reactive Antibodies (PRA)

Crossmatch

HLA typing

Six antigens, try to match as many as possible

Type of match is organ specific

Panel of Reactive Antibodies (PRA)

Shows sensitivity to various HLA's

May have high or low reactivity to potential donors

High PRA

Highly sensitized

Ig # of cytotoxic antibodies

Transplant contraindicated

Crossmatch

Determines existence of antibodies against the donor

Graft versus Host disease

1. graft rejects the host tissue

2. onset as early as 7-30 days post transplant

3. once is starts, little can be done

4. donor t cells attacking host cells

Graft versus Host disease target organs

Skin

Liver

GI

Graft versus Host disease Priority

Bacterial and Fungal infections

Graft versus Host disease s/s

pruritic or painful skin rash

Diarrhea

abdominal pain

GI bleeding

Malabsorption

Jaundice

Elevated LFTs

Coma

Graft versus Host disease prophylaxis/tx

Immunosuppressants

Priority with patient's on immunosuppressive therapy

Infection risk

Hyperacute rejection

Occurs within 24hrs of transplant

Must remove organ

Acute rejection

Occurs within first 6 months

Admit to hospital for increased immunosuppressants

Chronic Rejection

Occurs within months to years

Irreversible, leading to organ failure - no tx, just supportive

Organ is full of T and B cells, immune mediated injury

Fibrosis and scarring

Grapefruit Juice NC

Patient's on immunosuppressants cannot have grapefruit juice

Cyclosporine

Immunosuppressant

Given to transplant patients

Gengraf

Tacrolimus

Immunosuppressant

Given to transplant patients

Prograf

Basiliximab

Monoclonal antibody

Given to transplant patients

Simulect